The effect of socioeconomic deprivation on 12 month Traumatic Brain Injury (TBI) outcome

The TBI Model Systems Neighborhood Socioeconomic Disadvantage Index (TBIMS-NSDI): Development and Comparison to Individual Socioeconomic Characteristics

OBJECTIVE

To create a census-based composite neighborhood socioeconomic deprivation index (NSDI) from geocoded residential addresses and to quantify how NSDI aligns with individual-level socioeconomic factors among people with traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

People enrolled in the TBI Model Systems National Database (TBIMS NDB).

DESIGN

Secondary analysis of a longitudinal cohort study.

MAIN MEASURES

The TBIMS-NSDI was calculated at the census tract level for the United States population based on a principal components analysis of eight census tract-level variables from the American Community Survey. Individual socioeconomic characteristics from the TBIMS NDB were personal household income, education (years), and unemployment status. Neighborhood:Individual NSDI residuals represent the difference between predicted neighborhood disadvantage based on individual socioeconomic characteristics versus observed neighborhood disadvantage based on the TBIMS-NSDI .

RESULTS

A single principal component was found to encompass the eight socioeconomic neighborhood-level variables. It was normally distributed across follow-up years 2, 5, and 10 post-injury in the TBIMS NDB. In all years, the TBIMS-NDSI was significantly associated with individual-level measures of household income and education but not unemployment status. Males, persons of Black and Hispanic background, Medicaid recipients, persons with TBI caused by violence, and those living in urban areas, as well as in the Northeast or Southern regions of the United States, were more likely to have greater neighborhood disadvantage than predicted based on their individual socioeconomic characteristics.

CONCLUSIONS

The TBIMS-NSDI provides a neighborhood-level indicator of socioeconomic disadvantage, an important social determinant of outcomes from TBI. The Neighborhood:Individual NSDI residual adds another dimension to the TBIMS-NSDI by summarizing how a person's socioeconomic status aligns with their neighborhood socioeconomics. Future studies should evaluate how both measures affect TBI recovery and life quality. Research studying neighborhood socioeconomic disadvantage may improve our understanding of how systemic adversity influences outcomes after TBI.

Changes in depression symptoms over 10 years after TBI; a long-term prospective study

OBJECTIVE

Evaluate the prevalence and risk factors associated with depression symptoms at 10 years after traumatic brain injury (TBI) and compare with results at 10 weeks and 1 year.

METHODS

A large cohort of prospective admissions with TBI were followed up for 10 years. Depression using HADS (Hospital Anxiety and Depression Scale) score > 8 was measured. Several injury and demographic features were examined for association with depression.

RESULTS

Over 4 years, 1130 individuals were recruited of whom 916 attended at 1 year; after 10 years, 552 attended and 210 had died. 154 (17%) of the cohort was lost to follow-up. The prevalence of depression at 10 weeks was 56.3% [95%CI 52.2-60.5], at 1 year was 42.4% [95%CI 38.3-46.5] and 10 years 38.4% [95%CI 34.3-42.5]. There was considerable change in individual scores over time in both directions. A multivariable analysis identified the independent predictors of 10-year depression score as lower GCS, social deprivation, female gender, past psychiatric history, alcohol intoxication and unemployment. Age, ethnicity, social support, TBI etiology, CT abnormality and medical comorbidity were insignificant.

CONCLUSIONS

While the overall level of symptoms at 10-year post-TBI remains high, there is considerable change in individual depression status over time. The predictors identified may allow the targeting of vulnerable sub-populations.

Considering the Importance of Personal and Injury Factors Influencing Outcome After Traumatic Brain Injury

OBJECTIVE

Given the high variability in traumatic brain injury (TBI) outcomes and relative lack of examination of the influence of noninjury factors on outcome, this study aimed to examine factors associated with functional outcome at 1 and 2 years after moderate to severe TBI, including both preinjury and injury-related factors.

DESIGN

Observational cohort study.

SETTING

Inpatient hospital recruitment with outpatient follow-up at 1 and 2 years post injury.

PARTICIPANTS

Individuals with moderate to severe TBI were recruited prospectively into a Longitudinal Head Injury Outcome Study. Of the eligible 3253 individuals who were eligible, 1899 participants consented to the study (N=1899).

MAIN OUTCOME MEASURE

Functional outcome was measured using the Glasgow Outcome Scale-Extended (GOS-E).

RESULTS

1476 participants (73.6% males) and 1365 participants (73% males) completed the GOS-E at 1 and 2 years post injury. They had a mean age at injury of 40 years and mean duration of post-traumatic amnesia (PTA) of 26 days. Good recovery, representing return to previous activities on the GOS-E (score 7-8), was present in 31% of participants at 1 year post injury and 33.5% at 2 years post injury. When predictor variables were entered into regression together, good outcome was significantly associated with not being from a culturally and linguistically diverse background and not having preinjury mental health or alcohol treatment, shorter PTA duration, and absence of limb injuries at both 1 and 2 years; higher education was also a significant predictor at 1 year post injury.

CONCLUSIONS

Alongside consideration of injury severity, understanding and addressing preinjury factors is important to maximize outcomes.

Is Pre-Injury Socioeconomic Status Associated With Outcomes in Patients With Traumatic Brain Injury? A Systematic Review

While socioeconomic status (SES) is associated with a variety of health outcomes, the literature on the association between SES and traumatic brain injury (TBI) outcomes has not been formally summarized. This study aims to review existing literature to ascertain whether patients with low SES pre-injury have worse clinical outcomes after TBI compared with those with high SES, in high-income countries. A systematic search was conducted using the MEDLINE, Embase, and PsychINFO databases. Observational studies addressing the association between SES and TBI outcomes (mortality, functional, cognitive, and vocational outcomes) were included (published from 2000, written in English). Both pediatric and adult TBI groups were included. Thirty-two studies met the inclusion criteria. Measures of SES varied across studies. Mortality was assessed in seven studies; five reported an association between low SES and higher mortality. Five of eight studies showed an association between low SES and worse functional outcomes; results for cognitive (n = 13) and vocational outcomes (n = 10) were mixed. The results of this review suggest that SES is a variable of interest in the context of TBI outcomes and should be assessed at time of admission to assist in social work discharge planning and early mobilization of available community resources. Further work is required to better understand the impact of SES on TBI outcomes.

How Subjective and Objective Factors in Research and Practice May Perpetuate Health Disparities Among Patients With Traumatic Brain Injury

ABSTRACT

Research shows disparities exist in traumatic brain injury (TBI)-related outcomes and are associated with objective and subjective factors. Objective factors (e.g., age, sex, race/ethnicity, health insurance status, and socioeconomic status) are defined as variables that are frequently measured, not easily modifiable, and not easily influenced by individual perceptions, opinions, or experiences. Conversely, subjective factors (e.g., personal health literacy, cultural competence, patient/family-clinician communication, implicit bias, and trust) are defined as variables that may be less frequently measured, more easily modifiable, and more easily influenced by individual perceptions, opinions, or experiences. The purpose of this analysis and perspective is to provide recommendations for further examination of subjective factors within TBI research and practice, with the overarching goal of reducing TBI-related disparities. Establishing reliable and valid measures of subjective factors is recommended to allow for further examination of the influence of both objective factors and subjective factors in the TBI population. Providers and researchers must also engage in education and training to recognize their biases and how bias influences decision making. The influence of subjective factors in practice and research must also be considered to ensure that knowledge needed to advance health equity is generated and disparities in outcomes for patients with TBI are reduced.

You only get one brain: adult reflections on coping and recovery after traumatic brain injury in adolescence

BACKGROUND

TBI during adolescence can result in significant acute symptoms that can persist into adulthood. This research analyzed retrospective qualitative accounts of young adults who had sustained a TBI in adolescence to explore coping and recovery processes specific to this developmental stage.

METHODS

Thirteen adults (aged 20-25 years; mean 23 years) who sustained a mild (n = 12) or moderate (n = 1) TBI during adolescence (aged 13-17 years at injury), approximately 7.7 years (range = 6.7-8.0 years) prior, participated. Semi-structured individual interviews, analyzed using thematic analysis, explored participants' experiences following their TBIs.

RESULTS

Thematic data analysis produced two key categories of themes relating to recovery processes: (1) Individual factors impacting coping, with themes of learning to cope with difficulties, seeking acceptance and balance, and finding meaning; and (2) Social factors impacting coping, which included themes of feeling included, relying on family, professionals didn't get it, and lacking someone who understands.

CONCLUSIONS

Recovery following TBI sustained during adolescence could be maximized by facilitating greater understanding of specific impacts on young people among clinicians and family, longer term monitoring of symptoms including emotional reactions to symptoms, and the provision of emotional support.

A psychometric evaluation of a new social subscale for the Common Misconceptions about Traumatic Brain Injury (CM-TBI) questionnaire: toward the CM-TBI-II

OBJECTIVE

Existing TBI misconception measures are critiqued for failing to measure postinjury social experiences. This study developed a social subscale for the Common Misconceptions about TBI (CM-TBI) questionnaire for use in the general public.

METHODS

Seven experts independently review items drawn from the literature. Shortlisted items were administered online to 158 adults (aged ≥18 years; 51% postschool educated; 60% no TBI experience), the CM-TBI, and a measure of construct validity (a published TBI-adaptation of the Community Attitudes Towards the Mentally Ill; CAMI-TBI). One week later, the new items were redeployed (n = 46).

RESULTS

Expert review and iterative correlations identified a 10-item social subscale (internal consistency, test-retest reliability, α's>.80). When added to the CM-TBI (ie. CM-TBI-II), the internal consistency was .71. The social subscale was significantly correlated with CAMI-TBI measures (p's <.05, r's > .3). There was no significant difference on the social subscale for education subgroups (school vs post-school, p = 0.056) or previous TBI experience; but there was a difference for the CM-TBI-II (post-school>school; Cohen's d = 7.83, large effect).

CONCLUSION

This study found strong preliminary psychometric support for a new social subscale, administered as the CM-TBI-II. This subscale shows promise as a measure of misconceptions about social functioning post-TBI. The CM-TBI-II could support evaluations of programs aiming to improve social engagement and community participation for people with TBI.

Relationship Between Neighborhood Disadvantage and Mild Traumatic Brain Injury Symptoms

OBJECTIVE

To test the hypotheses that (1) higher neighborhood disadvantage is associated with greater injury-related symptom severity in civilians with mild traumatic brain injury (mTBI) and (2) neighborhood disadvantage remains predictive after controlling for other established predictors.

SETTING

Level 1 trauma center and affiliated academic medical center.

PARTICIPANTS

N = 171 individuals with mTBI.

DESIGN

Prospective cohort study.

MAIN MEASURES

Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score assessed less than 24 hours and at 2 weeks, 3 months, and 6 months postinjury. Linear mixed-effects models were used to assess the relationship between predictor variables and mTBI-related symptom burden (RPQ score). Neighborhood disadvantage was quantified by the Area Deprivation Index (ADI), a composite of 17 markers of socioeconomic position (SEP) scored at the census block group level.

RESULTS

Individuals in the upper ADI quartile of the national distribution displayed higher RPQ symptoms than those in the lower 3 quartiles ( P < .001), with a nonsignificant ADI × visit interaction ( P = .903). In a multivariable model, the effect of ADI remained significant ( P = .034) after adjusting for demographics, individual SEP, and injury factors. Other unique predictors in the multivariable model were gender (gender × visit P = .035), health insurance type ( P = .017), and injury-related litigation ( P = .012).

CONCLUSION

Neighborhood disadvantage as quantified by the ADI is robustly associated with greater mTBI-related symptom burden throughout the first 6 months postinjury. That the effect of ADI remained after controlling for demographics, individual SEP, and injury characteristics implies that neighborhood disadvantage is an important, understudied factor contributing to clinical recovery from mTBI.

Socioeconomic status is associated with mechanism and intent of injury in patients presenting to a UK Major Trauma Centre

BACKGROUND

Lower socioeconomic status (SES) is linked to poorer health, health outcomes and higher rates of trauma. The aim of this study was to investigate the impact SES had on the mechanism and intent of trauma in patients presenting to a UK regional Major Trauma Centre (MTC).

MATERIALS AND METHODS

Trauma data from a UK MTC over a five-year period was obtained from the Trauma Audit and Research Network. Deprivation data was obtained from English Indices of Multiple Deprivation 2019 data and the study population classified into quintiles. Odds ratios were calculated, comparing mechanism and intent of trauma with each SES quintile with the least deprived quintile as the baseline for comparison.

RESULTS

Lower SES was associated with an increased odds ratio of undifferentiated trauma (OR 1.32, P<0.001). Falls from less than 2m constitute most trauma presentations and were not associated with SES (OR 1.09, P=0.114, 58.3% of trauma). The greater odds ratios for trauma in the socially deprived was accounted for by an increase in high-energy mechanisms and injury intents that include falls more than 2m (OR 1.75), stabbing (OR 5.18), blow injury (OR 2.75), high-risk behaviour (OR 4.61), assault (OR 6.63) and self-harm (OR 2.94) (P-values <0.001).

CONCLUSION

In this large, retrospective analysis of a UK MTC, we have shown that the increased risk of trauma seen with lower SES is not uniform across all mechanisms or intents and is mediated by high-energy and violent mechanisms. Targeted public health education and intervention within these demographics, appropriate to mechanisms observed as over-represented, may prove beneficial in the primary prevention of trauma, and help to guide local health service planning.

"Can differences in hospitalised mild traumatic brain injury (mTBI) outcomes at 12 months be predicted?"

OBJECTIVES

To identify risk factors for poor outcome one year post-mild traumatic brain injury (mTBI).

DESIGN

This study was a prospective observational study using consecutive adult hospital admissions with mTBI.

SUBJECTS

A total of 869 consecutive mTBI patients were enrolled in this study.

METHODS

All patients were reviewed by the specialist TBI rehabilitation team at six weeks and one year following mTBI. Demographic and injury data collected included: age, gender, TBI severity and Glasgow Coma Scale (GCS). At twelve months, global outcome was assessed by the Extended Glasgow Outcome Score (GOSE) and participation restriction by the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) via semi-structured interview. An ordinal regression (OR) was used to identify associated factors for poor GOSE outcome and a linear regression for a poor RHFUQ outcome.

RESULTS

In the GOSE analysis, lower GCS (p < 0.001), medical comorbidity (p = 0.027), depression (p < 0.001) and male gender (p = 0.008) were identified as risk factors for poor outcome. The RHFUQ analysis identified: lower GCS (p = 0.002), female gender (p = 0.001) and injuries from assault (p = 0.003) were variables associated with worse social functioning at one year.

CONCLUSION

mTBI is associated with a significant impact upon the physical health and psychosocial function of affected individuals. The results of this study demonstrate that differences in mTBI outcome can be identified at twelve months post-mTBI and that certain features, particularly GCS, are associated with poorer outcomes.

Vocational Outcomes After Traumatic Brain Injury; Prevalence and Risk Factors After 1 Year in a Multivariable Model

OBJECTIVE

To determine the prevalence of employment status (ES) or full-time study after traumatic brain injury (TBI) in a representative population and its predictive factors.

DESIGN

Prospective cohort study.

SETTING

Regional Major Trauma Centre. Participants: In total, 1734 consecutive individuals of working age, admitted with TBI to a Regional Trauma Centre, were recruited and followed up at 8 weeks and 1 year with face-to-face interview. Median age was 37.2 years (17.5-58.2); 51% had mild TBI, and 36.8% had a normal computed tomographic (CT) scan. Main Outcome Measure: Complete or partial/modified return to employment or study as an ordinal variable.

RESULTS

At 1 year, only 44.9% returned to full-time work/study status, 28.7% had a partial or modified return, and 26.4% had no return at all. In comparison with status at 6 weeks, 9.9% had lower or reduced work status. Lower ES was associated with greater injury severity, more CT scan abnormality, older age, mechanism of assault, and presence of depression, alcohol intoxication, or a psychiatric history. The multivariable model was highly significant (P < .001) and had a Nagelkerke R2 of 0.353 (35.3%).

CONCLUSIONS

Employment at 1 year is poor and changes in work status are frequent, occurring in both directions. While associations with certain features may allow targeting of vulnerable individuals in future, the majority of model variance remains unexplained and requires further investigation.

Comorbidity in traumatic brain injury and functional outcomes: a systematic review

INTRODUCTION

Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.

EVIDENCE ACQUISITION

A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.

EVIDENCE SYNTHESIS

Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSIONS

Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).