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For: Yue JK, Krishnan N, Chyall L, Vega P, Hamidi S, Etemad LL, Tracey JX, Tarapore PE, Huang MC, Manley GT, DiGiorgio AM. Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury. Injury 2023;54:110815. [PMID: 37268533 DOI: 10.1016/j.injury.2023.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023]

For:	Yue JK, Krishnan N, Chyall L, Vega P, Hamidi S, Etemad LL, Tracey JX, Tarapore PE, Huang MC, Manley GT, DiGiorgio AM. Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury. Injury 2023;54:110815. [PMID: 37268533 DOI: 10.1016/j.injury.2023.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023]

Number

Cited by Other Article(s)

Martínez-Herrera E, Galindo-Oseguera E, Castillo-Cruz J, Fuentes-Venado CE, Gasca-López GA, Calzada-Mendoza CC, Ocharan-Hernández E, Zúñiga-Cruz CA, Farfán-García ED, Arellano-Ramírez A, Pinto-Almazán R. Mortality-Associated Factors in a Traumatic Brain Injury Population in Mexico. Biomedicines 2024;12:2037. [PMID: 39335550 PMCID: PMC11428733 DOI: 10.3390/biomedicines12092037] [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: 07/17/2024] [Revised: 08/23/2024] [Accepted: 09/02/2024] [Indexed: 09/30/2024] Open

Affiliation(s)

Erick Martínez-Herrera Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico Fundación Vithas, Grupo Hospitalario Vithas, 28043 Madrid, Spain Efficiency, Quality, and Costs in Health Services Research Group (EFISALUD), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36213 Vigo, Spain
Evelyn Galindo-Oseguera Maestría en Ciencias de la Salud, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico
Juan Castillo-Cruz Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico
Claudia Erika Fuentes-Venado Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico Servicio de Medicina Física y Rehabilitación, Hospital General de Zona No 197, Texcoco 56108, Mexico
Gilberto Adrián Gasca-López Dirección Médica, Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca 56530, Mexico
Claudia C Calzada-Mendoza Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico
Esther Ocharan-Hernández Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico
Carlos Alberto Zúñiga-Cruz Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico
Eunice D Farfán-García Laboratorio de Bioquímica, Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico
Alfredo Arellano-Ramírez Jefatura de Terapia Intensiva, Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca 56530, Mexico
Rodolfo Pinto-Almazán Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón, Ciudad de Mexico 11340, Mexico Fundación Vithas, Grupo Hospitalario Vithas, 28043 Madrid, Spain

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Yue JK, Etemad LL, Elguindy MM, van Essen TA, Belton PJ, Nelson LD, McCrea MA, Vreeburg RJG, Gotthardt CJ, Tracey JX, Coskun BC, Krishnan N, Halabi C, Eagle SR, Korley FK, Robertson CS, Duhaime AC, Satris GG, Tarapore PE, Huang MC, Madhok DY, Giacino JT, Mukherjee P, Yuh EL, Valadka AB, Puccio AM, Okonkwo DO, Sun X, Jain S, Manley GT, DiGiorgio AM, Badjatia N, Barber J, Bodien YG, Fabian B, Ferguson AR, Foreman B, Gardner RC, Gopinath S, Grandhi R, Russell Huie J, Dirk Keene C, Lingsma HF, MacDonald CL, Markowitz AJ, Merchant R, Ngwenya LB, Rodgers RB, Schneider ALC, Schnyer DM, Taylor SR, Temkin NR, Torres-Espin A, Vassar MJ, Wang KKW, Wong JC, Zafonte RD. Prior traumatic brain injury is a risk factor for in-hospital mortality in moderate to severe traumatic brain injury: a TRACK-TBI cohort study. Trauma Surg Acute Care Open 2024;9:e001501. [PMID: 39081460 PMCID: PMC11287071 DOI: 10.1136/tsaco-2024-001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024] Open

Abstract

ABSTRACT

Objectives

An estimated 14-23% of patients with traumatic brain injury (TBI) incur multiple lifetime TBIs. The relationship between prior TBI and outcomes in patients with moderate to severe TBI (msTBI) is not well delineated. We examined the associations between prior TBI, in-hospital mortality, and outcomes up to 12 months after injury in a prospective US msTBI cohort.

Methods

Data from hospitalized subjects with Glasgow Coma Scale score of 3-12 were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (enrollment period: 2014-2019). Prior TBI with amnesia or alteration of consciousness was assessed using the Ohio State University TBI Identification Method. Competing risk regressions adjusting for age, sex, psychiatric history, cranial injury and extracranial injury severity examined the associations between prior TBI and in-hospital mortality, with hospital discharged alive as the competing risk. Adjusted HRs (aHR (95% CI)) were reported. Multivariable logistic regressions assessed the associations between prior TBI, mortality, and unfavorable outcome (Glasgow Outcome Scale-Extended score 1-3 (vs. 4-8)) at 3, 6, and 12 months after injury.

Results

Of 405 acute msTBI subjects, 21.5% had prior TBI, which was associated with male sex (87.4% vs. 77.0%, p=0.037) and psychiatric history (34.5% vs. 20.7%, p=0.010). In-hospital mortality was 10.1% (prior TBI: 17.2%, no prior TBI: 8.2%, p=0.025). Competing risk regressions indicated that prior TBI was associated with likelihood of in-hospital mortality (aHR=2.06 (1.01-4.22)), but not with hospital discharged alive. Prior TBI was not associated with mortality or unfavorable outcomes at 3, 6, and 12 months.

Conclusions

After acute msTBI, prior TBI history is independently associated with in-hospital mortality but not with mortality or unfavorable outcomes within 12 months after injury. This selective association underscores the importance of collecting standardized prior TBI history data early after acute hospitalization to inform risk stratification. Prospective validation studies are needed.

Level of evidence

IV.

Trial registration number

NCT02119182.

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Affiliation(s)

John K Yue Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Leila L Etemad Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Mahmoud M Elguindy Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Thomas A van Essen Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands
Patrick J Belton Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
Lindsay D Nelson Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
Michael A McCrea Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
Rick J G Vreeburg Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands
Christine J Gotthardt Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Joye X Tracey Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Bukre C Coskun Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Nishanth Krishnan Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Cathra Halabi Neurology, University of California San Francisco, San Francisco, California, USA
Shawn R Eagle Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
Frederick K Korley Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
Claudia S Robertson Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA
Ann-Christine Duhaime Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
Gabriela G Satris Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Phiroz E Tarapore Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Michael C Huang Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Debbie Y Madhok Emergency Medicine, University of California San Francisco, San Francisco, California, USA
Joseph T Giacino Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA
Pratik Mukherjee Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
Esther L Yuh Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
Alex B Valadka Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
Ava M Puccio Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
David O Okonkwo Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
Xiaoying Sun Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Sonia Jain Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Geoffrey T Manley Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Anthony M DiGiorgio Neurological Surgery, University of California San Francisco, San Francisco, California, USA
On behalf of the TRACK-TBI Investigators Neurological Surgery, University of California San Francisco, San Francisco, California, USA
Neeraj Badjatia Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Jason Barber Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Yelena G Bodien Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Brian Fabian Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Adam R Ferguson Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Brandon Foreman Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Raquel C Gardner Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Shankar Gopinath Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Ramesh Grandhi Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
J Russell Huie Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
C Dirk Keene Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Hester F Lingsma Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Christine L MacDonald Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Amy J Markowitz Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Randall Merchant Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Laura B Ngwenya Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Richard B Rodgers Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Andrea L C Schneider Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
David M Schnyer Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Sabrina R Taylor Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Nancy R Temkin Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Abel Torres-Espin Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Mary J Vassar Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Kevin K W Wang Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Justin C Wong Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA
Ross D Zafonte Neurological Surgery, University of California San Francisco, San Francisco, California, USA Neurological Surgery, Leiden University Medical Center, Leiden, Netherlands Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA Neurology and Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Neurology, University of California San Francisco, San Francisco, California, USA Neurological Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Neurological Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Emergency Medicine, University of California San Francisco, San Francisco, California, USA Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts, USA Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA Neurological Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, California, USA

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Ding R, Deng M, Wei H, Zhang Y, Wei L, Jiang G, Zhu H, Huang X, Fu H, Zhao S, Yuan H. Machine learning-based prediction of clinical outcomes after traumatic brain injury: Hidden information of early physiological time series. CNS Neurosci Ther 2024;30:e14848. [PMID: 38973193 PMCID: PMC11228354 DOI: 10.1111/cns.14848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/16/2024] [Accepted: 06/27/2024] [Indexed: 07/09/2024] Open

Yue JK, Ramesh R, Krishnan N, Chyall L, Halabi C, Huang MC, Manley GT, Tarapore PE, DiGiorgio AM. Medicaid Insurance is a Predictor of Prolonged Hospital Length of Stay After Traumatic Brain Injury: A Stratified National Trauma Data Bank Cohort Analysis of 552 949 Patients. Neurosurgery 2024:00006123-990000000-01040. [PMID: 38305406 DOI: 10.1227/neu.0000000000002855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/17/2023] [Indexed: 02/03/2024] Open

Abstract

BACKGROUND AND OBJECTIVES

Hospital length of stay (HLOS) is a metric of injury severity, resource utilization, and healthcare access. Recent evidence has shown an association between Medicaid insurance and increased HLOS after traumatic brain injury (TBI). This study aims to validate the association between Medicaid and prolonged HLOS after TBI using the National Trauma Data Bank.

METHODS

National Trauma Data Bank Trauma Quality Programs Participant Use Files (2003-2021) were queried for adult patients with TBI using traumatic intracranial injury ICD-9/ICD-10 codes. Patients with complete HLOS, age, sex, race, insurance payor, Glasgow Coma Scale, Injury Severity Score, and discharge disposition data were included (N = 552 949). Analyses were stratified by TBI severity using Glasgow Coma Scale. HLOS was coded into Tiers according to percentiles within TBI severity categories (Tier 1: 1-74th; 2: 75-84th; 3: 85-94th; 4: 95-99th). Multivariable logistic regressions evaluated associations between insurance payor and prolonged (Tier 4) HLOS, controlling for sociodemographic, Injury Severity Score, cranial surgery, and discharge disposition variables. Adjusted odds ratios (aOR) and 95% CI were reported.

RESULTS

HLOS Tiers consisted of 0-19, 20-27, 28-46, and ≥47 days (Tiers 1-4, respectively) in severe TBI (N = 103 081); 0-15, 16-21, 22-37, and ≥38 days in moderate TBI (N = 39 904); and 0-7, 8-10, 11-19, and ≥20 days in mild TBI (N = 409 964). Proportion of Medicaid patients increased with Tier ([Tier 1 vs Tier 4] severe: 16.0% vs 36.1%; moderate: 14.1% vs 31.6%; mild TBI: 10.2% vs 17.4%; all P < .001). On multivariable analyses, Medicaid was associated with prolonged HLOS (severe TBI: aOR = 2.35 [2.19-2.52]; moderate TBI: aOR = 2.30 [2.04-2.61]; mild TBI: aOR = 1.75 [1.67-1.83]; reference category: private/commercial).

CONCLUSION

This study supports Medicaid as an independent predictor of prolonged HLOS across TBI severity strata. Reasons may include different efficacies in care delivery and reimbursement, which require further investigation. Our findings support the development of discharge coordination pathways and policies for Medicaid patients with TBI.

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Affiliation(s)

John K Yue Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Rithvik Ramesh Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Nishanth Krishnan Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Lawrence Chyall Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Cathra Halabi Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA Department of Neurology, University of California, San Francisco, San Francisco, California, USA Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
Michael C Huang Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Geoffrey T Manley Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Phiroz E Tarapore Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
Anthony M DiGiorgio Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA

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