Direct cost associated with acquired brain injury in Ontario

A qualitative study of individuals with acquired brain injury' and program facilitators' experiences in virtual acquired brain injury community support programs

PURPOSE

Acquired brain injury (ABI) community support programs aim to help support long-term needs through informational and psychosocial support. Due to the COVID-19 pandemic, many support programs adopted virtual program delivery. However, the experiences of facilitators and people with ABI who participate in virtual support programs are understudied. This study aimed to describe the experiences of people with ABI and program facilitators participating in virtual ABI community support programs.

MATERIALS AND METHODS

This was a qualitative descriptive study. Semi-structured interviews were conducted with people with ABI and program facilitators who participated in virtual ABI community support programs. Data were analyzed using inductive thematic analysis.

RESULTS

In total, 16 participants were included in this study. Of the 16 participants, 14 were people with ABI (three of whom were also program facilitators) and two were program facilitators without ABI. Our analysis generated three themes including perceived benefits (theme 1), perceived challenges (theme 2), and considerations to improve program quality (theme 3). Each theme outlines subthemes relaying the experiences of participants.

CONCLUSIONS

These findings highlight the need for stakeholders to implement guidelines and training for program facilitators and attendees of virtual ABI support programs to maximize accessibility, usability, inclusivity and safety.IMPLICATIONS FOR REHABILITATIONThis study described the experiences of people with acquired brain injury and facilitators who participated in virtual support programs.Benefits of virtual support programs include connecting with peers, increased access to resources, and enhanced feasibility and accessibility.Difficulties with virtual support programs include intrapersonal (e.g., increased side effects), interpersonal (e.g., communication barriers), and environmental and contextual (e.g., privacy concerns) challenges.Suggestions to improve program quality include creating a safe and respectful environment, fostering engagement and managing challenging situations, and enhancing accessibility and inclusivity.

Physicians' beliefs and perceived importance of traumatic brain injury-associated agitation in critically ill patients: a survey of Canadian intensivists

PURPOSE

Agitation is a common behavioural problem following traumatic brain injury (TBI). Intensive care unit (ICU) physicians' perspectives regarding TBI-associated agitation are unknown. Our objective was to describe physicians' beliefs and perceived importance of TBI-associated agitation in critically ill patients.

METHODS

Following current standard guidance, we built an electronic, self-administrated, 42-item survey, pretested it for reliability and validity, and distributed it to 219 physicians working in 18 ICU level-1 trauma centres in Canada. We report the results using descriptive statistics.

RESULTS

The overall response rate was 93/219 (42%), and 76/93 (82%) respondents completed the full survey. Most respondents were men with ten or more years of experience. Respondents believed that pre-existing dementia (90%) and regular recreational drug use (86%) are risk factors for agitation. Concerning management, 91% believed that the use of physical restraints could worsen agitation, 90% believed that having family at the bedside reduces agitation, and 72% believed that alpha-2 adrenergic agonists are efficacious for managing TBI agitation. Variability was observed in beliefs on epidemiology, sex, gender, age, socioeconomic status, and other pharmacologic options. Respondents considered TBI agitation frequent enough to justify the implementation of management protocols (87%), perceived the current level of clinical evidence on TBI agitation management to be insufficient (84%), and expressed concerns about acute and long-term detrimental outcomes and burden to patients, health care professionals, and relatives (85%).

CONCLUSION

Traumatic brain injury-associated agitation in critically ill patients was perceived as an important issue for most ICU physicians. Physicians agreed on multiple approaches to manage TBI-associated agitation although agreement on epidemiology and risk factors was variable.

Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures

Importance

Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex.

Objective

To examine the association between surgeon sex and health care costs among patients undergoing surgery.

Design, Setting, and Participants

This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023.

Exposure

Surgeon sex.

Main Outcome and Measure

The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates.

Results

Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202).

Conclusions and Relevance

This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Medical Care Among Individuals with a Concussion in Ontario: A Population-based Study

BACKGROUND

Concussion affects 1.2% of the population annually; rural regions and children have higher rates of concussion.

METHODS

Using administrative health care linked databases, all residents of Ontario with a physician diagnosed concussion were identified using ICD-9 code 850 or ICD-10 code S06. Cases were tracked for 2 years for concussion-related health care utilization with relevant specialist physicians (i.e., neurology, otolaryngology, physiatry, psychiatry, ophthalmology). Billing codes, specialist codes, and time from index to visit were analyzed. Factors associated with increased specialist visits were also examined.

RESULTS

In total, 1,022,588 cases were identified between 2008 and 2014 with 2 years of post-concussion health care utilization available. Follow-up by physician within 3 days of injury occurred in only 14% of cases. Mean time between ED diagnosis and follow-up by a physician was 83.9 days, whereas for rural regions it was >100 days. About half of adults (51.9%) and children (50.3%) had at least 1 specialist visit following concussion. Mean time between injury and first specialist visit was 203.8 (SD 192.9) days for adults, 213.5 (SD 201.0) days for rural adults, and 276.0 (SD 202.6) days for children. There were 67,420 neurology visits, 70,404 psychiatry visits, 13,571 neurosurgery visits, 19,780 physiatry visits, 101,788 ENT visits, and 103,417 ophthalmology visits in the 2 years tracking period. Factors associated with more specialist use included age > 18 years, urban residence, and pre-injury psychiatric history.

CONCLUSIONS

There are discrepancies in post-concussion health care utilization based on age group and rural/urban residence. Addressing these risk factors could improve concussion care access.

A Randomized Controlled Trial to Evaluate the Impact of an Exercise Therapy Program Based on Sports in People with Acquired Brain Injury: Discover Study Protocol

INTRODUCTION

Acquired brain injury (ABI) constitutes a significant and growing global public health concern. People with ABI often face a range of physical and psychosocial challenges that span the domains of "body structure and function", "activity", and "participation", as defined by the International Classification of Functioning, Disability, and Health. Multidisciplinary approaches based on exercise therapy with social leisure activities are essential to improve physical recovery and health-related quality of life after injury.

METHODS

Adults with ABI, aged > 18 years, in the subacute or chronic stage (within more than one month after the injury) will be recruited through a rehabilitation center. Adults will be randomized to receive either a racket sports-based exercise therapy program combined with usual care (sET) or usual care alone (UC) using a random number sequence with a 1:1 allocation ratio. sET intervention consists of an 8-week exercise therapy program focusing on different racket sports skills, 1 h in duration, 2 days/week. It will be delivered by a physiotherapist in tailored, face-to-face, group-based sessions. Primary outcomes will be the health-related quality of life (SF-36) and upper extremity motor function (Fugl-Meyer Assessment-Upper Extremity Scale).

DISCUSSION

The study proposes an intervention that combines sports-based exercise therapy with usual care. It aims to determine whether this intervention improves the health-related quality of life and upper limb motor function in adults with ABI compared with usual care alone. The results of this study may have clinical implications for the rehabilitation of this population.

Impact of the COVID-19 pandemic on community-based brain injury associations across Canada: a cross-sectional survey study

Background

The COVID-19 pandemic created new difficulties for people living with brain injury, their families, and caregivers while amplifying the challenges of community-based associations that support them. We aimed to understand the effects of the pandemic on clients who live with brain injury, as well as on the provision of community brain injury services/programs in Canada.

Methods

Online cross-sectional survey conducted in January 2022. Representatives of brain injury associations across Canada completed the 31 open- and closed-ended questions about meeting clients' needs, addressing public health guidelines, and sustaining the association. Data were analyzed using descriptive statistics (close-ended questions) and qualitative content analysis (open-ended questions).

Results

Of the 45 key representatives from associations in Pacific/Western (40%), Central (56%), and Atlantic Canada (4%), the majority were paid executive directors (67%). Participants reported that the most frequent psychosocial challenges experienced by their clients during the pandemic were social isolation (98%), loneliness (96%), and anxiety (93%). To alleviate these challenges, associations implemented wellness checks and psychosocial support. Most respondents (91%) affirmed that clients faced multiple technological barriers, such as a lack of technological knowledge and financial resources for devices and/or internet. In the open-ended questions, twenty-nine (64%) associations reported providing clients with devices, technology training, and assistance. Regarding public health measures, thirty (67%) respondents reported that clients had challenges understanding and/or following public health guidelines. Forty-two associations (93%) provided tailored information to help clients understand and comply with public health measures. Although associations (67%) received pandemic-related funding from the Canadian government they still struggled with the association's sustainability. Thirty-four (76%) lost funding or financial resources that prevented them from delivering programs or required the use of reserve funds to continue to do so. Only 56% reported receiving sufficient funding to address additional COVID-19-related expenses.

Conclusion

Although the pandemic added further challenges to the sustainability of brain injury associations across Canada, they quickly adapted services/programs to respond to the increasing and varied needs of clients, while complying with protective measures. To ensure community associations' survival it is essential to aptly recognize the vital role played by these associations within the brain injury care continuum.

Acquired Brain Injury Among Adolescents and Young Adults: A Nationwide Study of Labor Market Attachment

Purpose Young patients represent a particularly vulnerable group regarding vocational prognosis after an acquired brain injury (ABI). We aimed to investigate how sequelae and rehabilitation needs are associated with vocational prognosis up to 3 years after an ABI in 15-30-year-old patients. Methods An incidence cohort of 285 patients with ABI completed a questionnaire on sequelae and rehabilitation interventions and needs 3 months after the index hospital contact. They were followed-up for up to 3 years with respect to the primary outcome "stable return to education/work (sRTW)", which was defined using a national register of public transfer payments. Data were analyzed using cumulative incidence curves and cause-specific hazard ratios. Results Young individuals reported a high frequency of mainly pain-related (52%) and cognitive sequelae (46%) at 3 months. Motor problems were less frequent (18%), but negatively associated with sRTW within 3 years (adjusted HR 0.57, 95% CI 0.39-0.84). Rehabilitation interventions were received by 28% while 21% reported unmet rehabilitation needs, and both factors were negatively associated with sRTW (adjusted HR 0.66, 95% CI 0.48-0.91 and adjusted HR 0.72, 95% CI 0.51-1.01). Conclusions Young patients frequently experienced sequelae and rehabilitation needs 3 months post ABI, which was negatively associated with long-term labor market attachment. The low rate of sRTW among patients with sequelae and unmet rehabilitation needs indicates an untapped potential for ameliorated vocational and rehabilitating initiatives targeted at young patients.

Neurotrauma in Indigenous Populations of Canada-Challenges and Opportunities at a Global Level: A Scoping Review

BACKGROUND

Neurotrauma accounts for over 24,000 hospitalizations annually in Canada and has a significant impact in many developed countries. Among those affected, indigenous peoples are disproportionately impacted. The present scoping review explores the factors contributing to neurotrauma in indigenous populations and potential strategies to address this health care issue at a global level.

METHODS

A search was performed in Medline (1974-2021) and Embase (1946-2021) to identify studies pertaining to neurotrauma in indigenous populations of Canada. Search terms included 'Aboriginal', 'First Nation', 'Indigenous', 'traumatic brain injury', and 'traumatic spine injury'. Thematic analysis was then used to synthesize the information collected. A gray literature search was also performed.

RESULTS

The original literature search yielded 1609 articles, with 17 selected for the scoping review. Through thematic analysis, the factors contributing to neurotrauma burden in indigenous populations of Canada were summarized into 3 themes: inadequate resources available, social problems in indigenous communities, and challenges within the health care system. The potential strategies to address neurotrauma were also summarized into 3 themes: system-level changes to Canadian health care, community-based initiatives, and culturally appropriate solutions. The gray literature search revealed a lack of government reports on the topic and notable advocacy work from community organizations.

CONCLUSIONS

Systems-level interventions guided by indigenous community members will help to address the disparities that indigenous peoples face in the care and rehabilitation of neurotrauma. This study will inform further research of culturally appropriate approaches to reduce neurotrauma among indigenous peoples at a global level.

Value of Nonpharmacological Interventions for People With an Acquired Brain Injury: A Systematic Review of Economic Evaluations

OBJECTIVES

Acquired brain injury (ABI) has long-lasting effects, and patients and their families require continued care and support, often for the rest of their lives. For many individuals living with an ABI disorder, nonpharmacological rehabilitation treatment care has become increasingly important care component and relevant for informed healthcare decision making. Our study aimed to appraise economic evidence on the cost-effectiveness of nonpharmacological interventions for individuals living with an ABI.

METHODS

This systematic review was registered in PROSPERO (CRD42020187469), and a protocol article was subject to peer review. Searches were conducted across several databases for articles published from inception to 2021. Study quality was assessed according the Consolidated Health Economic Evaluation Reporting Standards checklist and Population, Intervention, Control, and Outcomes criteria.

RESULTS

Of the 3772 articles reviewed 41 publications met the inclusion criteria. There was a considerable heterogeneity in methodological approaches, target populations, study time frames, and perspectives and comparators used. Keeping these issues in mind, we find that 4 multidisciplinary interventions studies concluded that fast-track specialized services were cheaper and more cost-effective than usual care, with cost savings ranging from £253 to £6063. In 3 neuropsychological studies, findings suggested that meditated therapy was more effective and saved money than usual care. In 4 early supported discharge studies, interventions were dominant over usual care, with cost savings ranging from £142 to £1760.

CONCLUSIONS

The cost-effectiveness evidence of different nonpharmacological rehabilitation treatments is scant. More robust evidence is needed to determine the value of these and other interventions across the ABI care pathway.

The Socioeconomic Burden of Acquired Brain Injury among the Korean Patients over 20 Years of Age in 2015-2017: a Prevalence-Based Approach

Acquired brain injury (ABI) is a leading cause of serious long-term disability resulting in substantial economic costs for post-ABI care. This study was conducted to estimate the socioeconomic burden of persons with ABI in Korea. We used a prevalence-based approach and societal perspective to estimate the direct medical, non-medical costs and indirect costs of ABI, including stroke, traumatic brain injury (TBI), and non-traumatic ABI (anoxia, brain tumor, encephalitis, meningitis, hydrocephalus, and other brain disorders) from 2015 to 2017. The study population included patients with ABI over 20 years of age and analyzed according to insurance types encompassing National Health Insurance and automobile insurance. The socioeconomic burden of ABI was 4.67, 5.18, and 5.73 trillion KRW (approximately 4,162, 4,612, and 5,106 million USD) from 2015 to 2017 and around 0.3% of Korea's GDP annually. Estimating by disease, the socioeconomic cost was 72.4% for stroke, 18.6% for TBI, and 9.0% for non-traumatic ABI. Calculated by cost component, medical costs and non-medical costs showed a slight increase every year. Through this study, establishment of rehabilitation systems maximizing the health and quality of life for injured persons remain the key public health strategy for ABI to reduce socioeconomic burden and financial policies to support patients should be needed.

EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC): a protocol for an interprofessional mixed-method study

INTRODUCTION

Agitation and violent behaviours are common conditions developed by patients with acute traumatic brain injury (TBI) in intensive care units (ICUs). Healthcare professionals caring for these patients have various tools to manage these behaviours, but lack of a formal protocol to assess and manage them makes caring for these patients a challenge. Moreover, safety may often be compromised for both ICU professionals and patients encountering such situations. The EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC) study aims to explore the experiences and attitudes of ICU nurses and other ICU healthcare professionals on the management of agitated behaviours in patients with acute TBI.

METHODS AND ANALYSIS

EXSTATIC is a multicenter mixed methods convergent study exploring experiences and attitudes of ICU healthcare professionals caring of agitated patients with TBI. The study includes three qualitative methods (observation, semistructured interviews and focus groups) and one quantitative method (retrospective cohort). The integration of the different methods will be done using sequential steps of the research and by the integration of results for each step. Qualitative data will be evaluated following a thematic analysis derived from a grounded theory approach. Quantitative data will be analysed using descriptive statistics. Qualitative and quantitative results will be combined in a convergent interactive interpretative design. Gender and race perspective will be integrated in collection, analysis and interpretation of data.

ETHICS AND DISSEMINATION

This study has been approved by the Centre intégré universitaire de santé et de services sociaux du nord de l'île de Montréal (CIUSSS-NÎM) Research Ethics Board. The findings will be disseminated locally with ICU staff and health managers, international peer-reviewed journals, a PhD dissertation, and national and international conferences. The knowledge derived from this study is key in the development of clinical protocols to manage agitation and related behaviours in patients with TBI and designing further interventional studies targeting this specific problematic.

TRIAL REGISTRATION NUMBER

NCT04741399.

Sepsis in Traumatic Brain Injury: Epidemiology and Outcomes

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability. Risk factors for in-hospital mortality include older age, co-morbidity, and TBI severity. Few studies have investigated the role of sepsis in individuals with TBI.

METHODS

We studied adult patients with TBI admitted to intensive care over a 5-year period. Patient characteristics were identified by linking clinical and administrative databases. Charts of individuals with TBI and sepsis were manually reviewed. Predictors of ICU and hospital mortality were identified using logistic regression modeling.

RESULTS

Four hundred eighty-six individuals with TBI were admitted to intensive care. Sixteen (3.3%) developed sepsis. Pneumonia was the most common source (94%). Staphylococcus aureus was the most common pathogen (75%). ICU lengths of stay (LOS) (12.2 days [interquartile range (IQR) 4.4-23.5] versus 3.7 days [IQR 1.7-8.2]; p < 0.001) and hospital LOS (28.0 days [IQR 11.8-41.4] versus 15.3 days [IQR 5.0-30.9]; p = 0.017) were longer in patients with TBI and sepsis. Sepsis was not associated with ICU (adjusted odds ratio [aOR] 0.51; 95%CI 0.12-2.27; p = 0.38) or hospital (aOR 0.78; 95% CI 0.21-2.96; p = 0.78) mortality, though age (aOR 1.02; 95% CI 1.00-1.04; p = 0.014 for hospital mortality), severe TBI (aOR 3.71; 95% CI 1.52-9.08; p = 0.004 for ICU mortality and 4.10; 95% CI 1.95-8.65; p < 0.001 for hospital mortality), and APACHE II score (aOR 1.19; 95% CI 1.11-1.28; p < 0.001 for ICU mortality and 1.22; 95% CI 1.14-1.31; p < 0.001 for hospital mortality) were.

CONCLUSION

Sepsis in patients with TBI was not associated with mortality; however, sepsis was associated with increased health care utilization (ICU and hospital LOS).

Healthcare Utilization Following Traumatic Brain Injury in a Large National Sample

OBJECTIVE

To evaluate the impact of traumatic brain injury (TBI) on healthcare utilization (HCU) over a 1-year period in a large national sample of individuals diagnosed with TBI across multiple care settings.

SETTING

Commercial insurance enrollees.

PARTICIPANTS

Individuals with and without TBI, 2008-2014.

DESIGN

Retrospective cohort.

MAIN MEASURES

We compared the change in the 12-month sum of inpatient, outpatient, emergency department (ED), and prescription HCU from pre-TBI to post-TBI to the same change among a non-TBI control group. Most rehabilitation visits were not included. We stratified models by age ≥65 and included the month of TBI in subanalysis.

RESULTS

There were 207 354 individuals in the TBI cohort and 414 708 individuals in the non-TBI cohort. Excluding the month of TBI diagnosis, TBI resulted in a slight increase in outpatient visits (rate ratio [RtR] = 1.05; 95% confidence interval [CI], 1.04-1.06) but decrease in inpatient HCU (RtR = 0.86; 95% CI, 0.84-0.88). Including the month of TBI in the models resulted in increased inpatient (RtR = 1.55; 95% CI, 1.52-1.58) and ED HCU (RtR = 1.37; 95% CI, 1.34-1.40).

CONCLUSION

In this population of individuals who maintained insurance coverage following TBI, results suggest that TBI may have a limited impact on nonrehabilitation HCU at the population level.

The effectiveness of community neurorehabilitation for persons with an acquired brain injury: protocol for a systematic review

Background: Acquired brain injury (ABI) refers to any type of brain damage after birth.  ABI from either traumatic or non-traumatic origin is a leading cause of death and long-term disability globally.  The impact of an ABI can be cognitive and/ or physical, greatly affecting their ability to function independently.  With a lack of specialist inpatient rehabilitation facilities and services many of these survivors reside within the community either alone, with family or in residential facilities.  Up-to-date evidence is required to indicate which forms of community rehabilitation are most effective in improving cognitive and physical outcomes for survivors. This systematic review aims to explore the clinical effectiveness of community neuro-rehabilitation services for persons living with an ABI. Methods: A systematic review of relevant electronic databases will be undertaken to identify eligible published randomised controlled trials.  The PRISMA statement will be used to guide the systematic review.  From running the initial search, we aim to submit the paper for publishing within 6 months.  This process will be completed using Covidence software.  Two reviewers will independently screen the search results and select studies using pre-defined selection criteria, extract data from and assess risk of bias for selected studies.     Discussion: This systematic review will aim to explore the clinical effectiveness of community neuro-rehabilitation services for persons with an ABI.  It plans to review and synthesize the current best available evidence base. A goal of this study is to positively inform ongoing service development within a quality framework. Systematic review registration: PROSPERO CRD42020148604 (26/02/2020)

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

OBJECTIVE

To identify determinants of discharge disposition from acute care among survivors of hypoxic-ischemic brain injury (HIBI), stratified by sex.

DESIGN

Population-based retrospective cohort study using provincial data in Ontario, Canada. The determinants were grouped into predisposing, need, and enabling factors using the Anderson Behavioral Model.

SETTING

Acute care.

PARTICIPANTS

Survivors of HIBI aged ≥20 years at the time of hospitalization and discharged alive from acute care between April 1, 2002, and March 31, 2017. There were 7492 patients with HIBI, of whom 28% (N=2077) survived their acute care episode.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge disposition from acute care, categorized as complex continuing care (CCC), long-term care (LTC), inpatient rehabilitation (IR), home with support, home without support, and transferred to another acute care.

RESULTS

The discharge dispositions for the 2077 survivors were IR 23.4% (n=487), CCC 19.5% (n=404), LTC 6.2% (n=128), home without support 31.2% (n=647), home with support 15.1% (n=314), and other 4.6%. Multinomial multivariable logistic regression analysis using home without support as the reference category revealed that female patients were significantly more likely than male patients to be discharged to LTC/CCC. Those who were older, were frail, and had longer stay in acute care or special care unit (SCU) were more likely to be discharged to LTC/CCC. The only significant determinant for IR was longer stay in acute care. Survivors with cardiac-related injury were less likely to be discharged to LTC/CCC. Income was a significant factor for male patients but not for female patients in the sex-stratified analysis. The following variables were investigated but were not significant determinants in this study: need factors (comorbidity score, prior psychiatric disorders, health care utilization) and enabling factors (income quintile, rural area of residence).

CONCLUSIONS

Predisposing (age, sex) and need factors (frailty, acute care days, SCU days, type of injury) were significant determinants of discharge disposition from acute care after HIBI. In spite of a system with universal coverage, sex differences were found, with more female patients being discharged to CCC/LTC rather than IR, controlling for age and other confounders. These findings should be considered in appropriate discharge planning from acute care for survivors of HIBI.

Misperception of sleep duration in mild traumatic brain injury/concussion: a preliminary report

Background: Polysomnographic (PSG) findings of persons with mild traumatic brain injury (mTBI)/concussion show longer total sleep time than patients themselves report; the reason for this is not entirely clear.Objective: This study aimed to elucidate the socio-demographic, brain-injury-related, and clinical characteristics that underlie accuracy of sleep duration reporting in mTBI/concussion.Methods: Thirty-seven participants diagnosed with mTBI/concussion (57% male, 47.54 ± 11.3 years old) underwent clinical and neuroimaging examinations, full-night PSG, and estimated sleep duration following PSG.Results: Mean self-reported sleep duration was 342 ± 93.6 minutes and PSG-measured sleep duration was 382 ± 76.8 minutes. Measurements were moderately correlated (rho = 0.46, p = .004). Age associated with self- and PSG-measured sleep duration (rho = 0.34 and rho = 0.84, respectively, p < .05). Self-reported sleep duration was uniquely associated with insomnia severity (rho = -0.48, p = .002). In the fully adjusted multivariable regression analysis, several clinical characteristics of patients explained 30% of the discrepancy between self- and PSG-measured sleep duration.Conclusion: The observed results indicate that persons with mTBI do not accurately assess their sleep duration and, therefore, PSG is warranted in clinical situations where sleep duration is of concern.

Early predictors of discharge to home among severely injured geriatric patients: A single-system retrospective cohort study

Background

Injured geriatric patients experience significant functional decline during their hospitalization, limiting their ability to be discharged home which is a valuable outcome among this vulnerable population. We therefore sought to evaluate the clinical characteristics of injured elderly patients managed within our trauma system and identify early predictors for discharge to home.

Methods

In this single-system retrospective cohort study, we evaluated significantly injured (Injury Severity Score ≥12) geriatric (age ≥65 y) patients admitted from Northern Alberta between 2011 and 2016. The primary outcome was discharge disposition to home. Data was analyzed with descriptive statistics, and univariable and multivariable logistic regression modelling. P values less than 0.05 were considered statistically significant.

Results

We identified 1548 patients with a median age of 77. Falls accounted for 47% of injuries with median injury severity score of 22; 47% of patients were discharged home with a median hospital length of stay of 8 days. All-cause in-hospital mortality was 19%. On multivariable regression, age, injury severity score, heart rate, systolic blood pressure, and Glasgow Coma Score were independent predictors for discharge home, as well as hospital and intensive care unit length of stay.

Conclusion

Nearly half of severely injured geriatric trauma patients were discharged home. The identified predictors provide clues to disposition on admission that trauma providers may use to guide in-hospital care planning, disposition planning, and stimulate early goals of care discussions.

Neuropsychological rehabilitation interventions for people with an acquired brain injury. A protocol for a systematic review of economic evaluation

Background: New emerging evidence has demonstrated the need for effective interventions to help people living with an acquired brain injury (ABI). Evidence on cost-effectiveness, which can help inform use of limited resources, is scarce in this area and therefore the purpose of this systematic review is to critically appraise and consolidate the current evidence on economic evaluations of ABI rehabilitation interventions. Methods: Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial-based model economic evaluations) of ABI treatment interventions in adults. A systematic literature search will be conducted on the following electronic databases: EMBASE, Econlit, CINAHL, Medline, the National Health Service Economic Evaluation Database and PsyclNFO. This review will only include cost-effectiveness analysis studies (e.g., cost per life year gained), cost-benefit and cost minimisation analyses in which the designs were randomised controlled trials (RCTs), non-RCT studies, cost-utility analyses (e.g., cost per quality-adjusted life year (QALY) gained or cost per disability-adjusted life year averted), cohort studies, and modelling studies. Only studies that were published in the english language, associated with adults who have an ABI will be included. There will be no restrictions on perspective, sample size, country, follow-up duration or setting. The search strategy terms will include the following: acquired brain injury, brain*; cost*; or cost-benefit analysis*. Following data extraction, a narrative summary and tables will be used to summarize the characteristics and results of included studies. Discussion: The findings from this review will be beneficial to health policy decision makers when examining the evidence of economic evaluations in this field. In addition, it is anticipated that this review will identify gaps in the current economic literature to inform future-related research. Systematic review registration: PROSPERO CRD42020187469 (25 th June 2020).

Identification of Abusive Head Trauma in High-Risk Infants: A Cost-Effectiveness Analysis

OBJECTIVES

To evaluate the cost-effectiveness of abusive head trauma detection strategies in emergency department settings with and without rapid magnetic resonance imaging (rMRI) availability.

STUDY DESIGN

A Markov decision model estimated outcomes in well-appearing infants with high-risk chief complaints. In an emergency department without rMRI, we considered 3 strategies: clinical judgment, universal head computed tomography (CT) scan, or the Pittsburgh Infant Brain Injury Score (PIBIS) with a CT scan. In an emergency department with rMRI for brain availability, we considered additional strategies: universal rMRI, universal rMRI with a CT scan, PIBIS with rMRI, and PIBIS with rMRI followed by a CT scan. Correct diagnosis eliminated future risk; missed abusive head trauma led to reinjury risk with associated poor outcomes. Cohorts were followed for 1 year from a healthcare perspective. One-way and probabilistic sensitivity analyses were performed. The main outcomes evaluated in this study were abusive head trauma correctly identified and incremental cost per quality-adjusted life-year.

RESULTS

Without rMRI availability, PIBIS followed by a CT scan was the most cost-effective strategy. Results were sensitive to variation of CT scan-induced cancer parameters and abusive head trauma prevalence. When rMRI was available, universal rMRI followed by a confirmatory CT scan cost $25 791 to gain 1 additional quality-adjusted life-year compared with PIBIS followed by rMRI with a confirmatory CT scan. In both models, clinical judgement was less effective than alternative strategies.

CONCLUSIONS

By applying CT scans to a more targeted population, PIBIS decreases radiation exposure and is more effective for the identification of abusive head trauma compared with clinical judgment. When rMRI is available, universal rMRI with a CT scan is more effective than PIBIS and is economically favorable.

Neuropsychological rehabilitation interventions for people with an acquired brain injury and their caregivers. A protocol for a systematic review of economic evaluation

Background: New emerging evidence has demonstrated the need for effective interventions to help people living with an acquired brain injury (ABI). Evidence on cost-effectiveness, which can help inform use of limited resources, is scarce in this area and therefore the purpose of this systematic review is to critically appraise and consolidate the current evidence on economic evaluations of ABI rehabilitation interventions. Methods: Systematic review methodology will be applied to identify, select and extract data from published economic evaluation studies (trial-based, non-trial based, simulation-based, decision model and trial-based model economic evaluations) of ABI treatment interventions in adults. A systematic literature search will be conducted on the following electronic databases: EMBASE, Econlit, CINAHL, Medline, Econlit, the National Health Service Economic Evaluation Database and PsyclNFO. This review will only include cost-effectiveness analysis studies (e.g., cost per life year gained), cost-benefit and cost minimisation analyses in which the designs were randomised controlled trials (RCTs), non-RCT studies, cost-utility analyses (e.g., cost per quality-adjusted life year (QALY) gained or cost per disability-adjusted life year averted), cohort studies, and modeling studies. Only studies that were published in English, associated with adults who have an ABI will be included. There will be no restrictions on perspective, sample size, country, follow-up duration or setting. The search strategy terms will include the following: acquired brain injury, brain*; cost*; or cost-benefit analysis*. Following data extraction, a narrative summary and tables will be used to summarize the characteristics and results of included studies. Discussion: The findings from this review will be beneficial to health policy decision makers when examining the evidence of economic evaluations in this field. In addition, it is anticipated that this review will identify gaps in the current economic literature to inform future-related research. Systematic review registration: PROSPERO CRD42020187469 (25 th June 2020).

A population-based sex-stratified study to understand how health status preceding traumatic brain injury affects direct medical cost

OBJECTIVE

To understand how pre-injury health status present five-years preceding traumatic brain injury (TBI) affects direct medical cost two years post-injury.

METHODS

Patients age ≥19 years in the emergency department (ED) or acute care for a TBI between April 1, 2007 and March 31, 2014 in Ontario, Canada (N = 55,669) were identified from population-based health administrative data. Forty-three factors of pre-injury health status (i.e., comorbidities and personal, social, and environmental factors) that were internally validated for the TBI population were assessed in this study. The outcome of interest was direct medical cost within two years of discharge. Sex-specific multivariable linear regressions were conducted to understand the associations between direct medical cost within two years of discharge and pre-injury health status.

RESULTS

Patients who received care in the ED (81.9% of total sample) incurred a median cost of $2,492/male patient (average $12,342/patient) and $3,508/female patient (average $65,285/patient) within two years of injury; 37 pre-injury factors were significantly associated with increased direct medical costs. Patients who first received care for their TBI in acute care (18.1%) incurred a median cost of $25,081/male patient (average $63,060/patient) and $30,277/female patient (average $65,285/patient) within two years of injury; 21 factors were significantly associated with increased direct medical costs. Among more prevalent factors, those associated with increased medical cost by at least 50% included mental health disorders, substance abuse, disorders or medical conditions frequently observed among the elderly, cardiovascular disorders, stroke and emergencies involving the brain, metabolic disorders and abdominal symptoms, conditions and symptoms of abdomen and pelvis, genitourinary disorders and disorders of prostate, and pulmonary abdominal and other emergencies.

CONCLUSIONS

Direct medical costs two years post-TBI differed significantly between patients with and without adverse pre-existing health status. Interdisciplinary teams to promote early identification of pre-existing health conditions and appropriate management and integration of these conditions in TBI care across the continuum of healthcare may be opportunities to reduce direct medical costs post-injury.

The Role of NLRP3 Inflammasome in the Pathogenesis of Traumatic Brain Injury

Traumatic brain injury (TBI) represents an important problem of global health. The damage related to TBI is first due to the direct injury and then to a secondary phase in which neuroinflammation plays a key role. NLRP3 inflammasome is a component of the innate immune response and different diseases, such as neurodegenerative diseases, are characterized by NLRP3 activation. This review aims to describe NLRP3 inflammasome and the consequences related to its activation following TBI. NLRP3, caspase-1, IL-1β, and IL-18 are significantly upregulated after TBI, therefore, the use of nonspecific, but mostly specific NLRP3 inhibitors is useful to ameliorate the damage post-TBI characterized by neuroinflammation. Moreover, NLRP3 and the molecules associated with its activation may be considered as biomarkers and predictive factors for other neurodegenerative diseases consequent to TBI. Complications such as continuous stimuli or viral infections, such as the SARS-CoV-2 infection, may worsen the prognosis of TBI, altering the immune response and increasing the neuroinflammatory processes related to NLRP3, whose activation occurs both in TBI and in SARS-CoV-2 infection. This review points out the role of NLRP3 in TBI and highlights the hypothesis that NLRP3 may be considered as a potential therapeutic target for the management of neuroinflammation in TBI.

Getting motivated: long-term perspectives on engaging in community-based programs after acquired brain injury

BACKGROUND

Low motivation is a common problem after acquired brain injury (ABI) and can persist for years after injury. Little is known, however, about perspectives of motivation with respect to engaging in the community, many years after ABI.

PURPOSE

To explore the client with ABI perspective of motivation and engagement in individuals based in community ABI programs.

METHOD

Interpretive description methods were utilized. Semi-structured interviews were conducted with 21 individuals with an ABI.

FINDINGS

Participants felt that both internal factors, such as feelings of hope, and external factors, such as social support, influence levels of motivation to engage. When positive internal and external motivators were enhanced, and negative internal and external motivators reduced, this gave rise to a sense of choice and control, which led to increased engagement.

IMPLICATIONS

Fostering positive aspects of rehabilitation and increasing choice and control may promote engagement. External motivators, such as reducing repetitiveness and promoting peer support, are motivators that community and clinical settings can implement relatively easily, whilst internal motivators such as attitudes toward therapy may need to be addressed continuously to enhance motivation and engagement.

Excess Mortality Among Adults Hospitalized With Traumatic Brain Injury in Australia: A Population-Based Matched Cohort Study

OBJECTIVE

To quantify and describe excess mortality attributable to traumatic brain injury (TBI) during the 12 months after hospitalization.

DESIGN

Population-based matched cohort study using linked hospital and mortality data.

SETTING

Australia.

PARTICIPANTS

Individuals 18 years and older who were hospitalized with a principal diagnosis of TBI in 2009 (n = 6929) and matched noninjured individuals randomly selected from the electoral roll (n = 6929).

MAIN MEASURES

Survival distributions were compared using a Kaplan-Meier plot with a log-rank test. Mortality rate ratios (MRRs) were computed using Cox proportional hazard regression with and without controlling for demographic characteristics and preexisting health status.

RESULTS

Individuals with TBI experienced significantly worse survival during the 12 months after hospitalization (χ = 640.9, df = 1, P < .001), and were more than 7.5 times more likely to die compared with their noninjured counterparts (adjusted MRR, 7.76; 95% confidence interval, 6.07-9.93). TBI was likely to be a contributory factor in 87% of deaths in the TBI cohort. Excess mortality was higher among males, younger age groups, and those with more severe TBI.

CONCLUSION

Excess mortality is high among individuals hospitalized with TBI and most deaths are attributable to the TBI. Increased primary and secondary preventive efforts are warranted to reduce the mortality burden of TBI.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study

BACKGROUND

The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI.

METHODS

We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation.

RESULTS

A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%).

CONCLUSION

In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

Data Mining to Understand How Health Status Preceding Traumatic Brain Injury Affects Functional Outcome: A Population-Based Sex-Stratified Study

OBJECTIVES

To understand how health status preceding traumatic brain injury (TBI) affects relative functional gain after inpatient rehabilitation using a data mining approach.

DESIGN

Population-based, sex-stratified, retrospective cohort study using health administrative data from Ontario, Canada (39% of the Canadian population).

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Patients 14 years or older (N=5802; 63.4% male) admitted to inpatient rehabilitation within 1 year of a TBI-related acute care discharge between April 1, 2008, and March 31, 2015.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Relative functional gain (RFG) in percentage, calculated as ([discharge FIM-admission FIM]/[126-admission FIM]×100). Health status prior to TBI was identified and internally validated using a data mining approach that categorized all International Classification of Diseases, 10th revision, codes for each patient.

RESULTS

The average RFG was 52.8%±27.6% among male patients and 51.6%±27.1% among female patients. Sex-specific Bonferroni adjusted multivariable linear regressions identified 10 factors of preinjury health status related to neurology, emergency medicine, cardiology, psychiatry, geriatrics, and gastroenterology that were significantly associated with reduced RFG in FIM for male patients. Only 1 preinjury health status category, geriatrics, was significantly associated with RFG in female patients.

CONCLUSIONS

Comorbid health conditions present up to 5 years preceding the TBI event were significantly associated with RFG. These findings should be considered when planning and executing interventions to maximize functional gain and to support an interdisciplinary approach. Best practices guidelines and clinical interventions for older male and female patients with TBI should be developed given the increasingly aging population with TBI.

Factors associated with emergency department presentation after total joint arthroplasty: a population-based retrospective cohort study

BACKGROUND

Unplanned visits to the emergency department after total joint arthroplasty are far more common than unplanned readmissions. Our objectives were to characterize the prevalence of presentation to an emergency department for any reason after total joint arthroplasty and to identify risk factors for such visits.

METHODS

Using health administrative databases, we conducted a population-based retrospective cohort study of adults (19-89 yr of age) who received their first primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure for arthritis between April 2011 and March 2016 in Ontario. We made univariate comparisons between patients who presented to the emergency department within 30 days of surgery and those who did not in. We determined differences in use of health care services between groups by comparing the change in use in the year before and after surgery between patients who presented to the emergency department and those who did not. We developed logistic regression models for the occurrence of an emergency department visit using backward variable elimination.

RESULTS

We identified 42 273 total hip recipients and 70 725 total knee recipients, of whom 5640 (13.3%) and 11 224 (15.9%), respectively, presented to the emergency department within 30 days of surgery. Fewer than 1% of these patients required admission, and nearly half (45%) went to a different institution from where they had their surgery. Among both THA and TKA recipients, patients who presented to the emergency department had a net increase in their median annual health care costs (THA: $501, TKA: $682), compared to a net decrease for the cohort as a whole. Factors associated with increased risk of an emergency visit included increased patient age, male sex, rural residence and various comorbidities. Predictive regression models showed poor discriminative ability for both THA (C-statistic 0.57) and TKA (C-statistic 0.58) recipients.

INTERPRETATION

One in 7 patients presented to the emergency department within 30 days of THA or TKA. Some may conceivably have been managed remotely, and very few required readmission. There is a crucial need for strategies to minimize these events.

Temporal Trends in Healthcare Costs and Outcome Following ICU Admission After Traumatic Brain Injury

Supplemental Digital Content is available in the text.

Objective:

To assess temporal trends in 1-year healthcare costs and outcome of intensive care for traumatic brain injury in Finland.

Design:

Retrospective observational cohort study.

Setting:

Multicenter study including four tertiary ICUs.

Patients:

Three thousand fifty-one adult patients (≥ 18 yr) with significant traumatic brain injury treated in a tertiary ICU during 2003–2013.

Intervention:

None.

Measurements and Main Results

: Total 1-year healthcare costs included the index hospitalization costs, rehabilitation unit costs, and social security reimbursements. All costs are reported as 2013 U.S. dollars ($). Outcomes were 1-year mortality and permanent disability. Multivariate regression models, adjusting for case-mix, were used to assess temporal trends in costs and outcome in predefined Glasgow Coma Scale (3–8, 9–12, and 13–15) and age (18–40, 41–64, and ≥ 65 yr) subgroups. Overall 1-year survival was 76% (n = 2,304), and of 1-year survivors, 37% (n = 850) were permanently disabled. Mean unadjusted 1-year healthcare cost was $39,809 (95% CI, $38,144–$41,473) per patient. Adjusted healthcare costs decreased only in the Glasgow Coma Scale 13–15 and 65 years and older subgroups, due to lower rehabilitation costs. Adjusted 1-year mortality did not change in any subgroup (p < 0.05 for all subgroups). Adjusted risk of permanent disability decreased significantly in all subgroups (p < 0.05).

Conclusion:

During the last decade, healthcare costs of ICU-admitted traumatic brain injury patients have remained largely the same in Finland. No change in mortality was noted, but the risk for permanent disability decreased significantly. Thus, our results suggest that cost-effectiveness of traumatic brain injury care has improved during the past decade in Finland.

Pharmacological interventions for agitated behaviours in patients with traumatic brain injury: a systematic review

OBJECTIVE

The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain injury (TBI).

METHODS

We performed a search strategy in PubMed, OvidMEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science and Prospero (up to 10 December 2018) for published and unpublished evidence on the risks and benefits of 9 prespecified medications classes used to control agitated behaviours following TBI. We included all randomised controlled trials, quasi-experimental and observational studies examining the effects of medications administered to control agitated behaviours in TBI patients. Included studies were classified into three mutually exclusive categories: (1) agitated behaviour was the presenting symptom; (2) agitated behaviour was not the presenting symptom, but was measured as an outcome variable; and (3) safety of pharmacological interventions administered to control agitated behaviours was measured.

RESULTS

Among the 181 articles assessed for eligibility, 21 studies were included. Of the studies suggesting possible benefits, propranolol reduced maximum intensities of agitation per week and physical restraint use, methylphenidate improved anger measures following 6 weeks of treatment, valproic acid reduced weekly agitated behaviour scale ratings and olanzapine reduced irritability, aggressiveness and insomnia between weeks 1 and 3 of treatment. Amantadine showed variable effects and may increase the risk of agitation in the critically ill. In three studies evaluating safety outcomes, antipsychotics were associated with an increased duration of post-traumatic amnesia (PTA) in unadjusted analyses. Small sample sizes, heterogeneity and an unclear risk of bias were limits.

CONCLUSIONS

Propranolol, methylphenidate, valproic acid and olanzapine may offer some benefit; however, they need to be further studied. Antipsychotics may increase the length of PTA. More studies on tailored interventions and continuous evaluation of safety and efficacy throughout acute, rehabilitation and outpatient settings are needed.

PROSPERO REGISTRATION NUMBER

CRD42016033140.

In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment

Background

The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology.

Methods

A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement.

Results

Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported.

Conclusions

Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.

Comparing Complications and Costs of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: A Propensity Score-Matched, Population-Based Study

BACKGROUND

Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population.

METHODS

A population-based, retrospective cohort study was performed on adults (≥60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure.

RESULTS

Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001).

CONCLUSIONS

Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Pilot Randomised Double-Blind Study of the Tolerability and efficacy of repetitive Transcranial Magnetic Stimulation on Persistent Post-Concussion Syndrome

This study investigates the effect of Repetitive Transcranial Magnetic Stimulation (rTMS) on persistent post-concussion syndrome (PCS). The study design was a randomized (coin toss), placebo controlled, and double-blind study. Thirty-seven participants with PCS were assessed for eligibility; 22 were randomised and 18 completed the study requirements. Half the participants with PCS were given an Active rTMS intervention and the other half given Sham rTMS over 3 weeks. Follow ups were at the end of treatment and at 30 and 60 days. The primary outcome measure was the Rivermead Post-Concussion Symptoms Questionnaire (RPQ3 & RPQ13). The results indicate participants with more recent injuries (<12 month), who received Active rTMS, showed significant improvements compared to those of: 1) the same subgroup who received Sham, and 2) those with a longer duration of injury (>14 months) who received Active rTMS. This improvement predominantly manifested in RPQ13 in the follow up periods 1 and 2 months after the intervention (RPQ13 change (mean ± SD): at 1 month, Active = −21.8 ± 6.6, Sham = −2.2 ± 9.8; at 2 months, Active = −21.2 ± 5.3, Sham = −5.4 ± 13.7). No improvement was found in the subgroup with longer duration injuries. The results support rTMS as a tolerable and potentially effective treatment option for individuals with a recent (<1 year) concussion.

The cost of treatment and its related complications for men who receive surgery or radiation therapy for prostate cancer

INTRODUCTION

We sought to examine the costs related to treatment and treatment-related complications for patients treated with surgery or radiation for localized prostate cancer.

METHODS

We performed a population-based, retrospective cohort study of men who underwent open radical prostatectomy or radiation from 2004-2009 in Ontario, Canada. Costs, including initial treatment and inpatient hospitalization, emergency room visit, outpatient consultation, physician billings, and medication costs, were determined for five years following treatment using a validated costing algorithm. Multivariable negative binomial regression was used to assess the association between treatment modality and costs.

RESULTS

A total of 28 849 men underwent treatment for localized prostate cancer from 2004- 2009. In the five years following treatment, men who underwent radiation (n=12 675) had 21% higher total treatment and treatment-related costs than men who underwent surgery ($16 716/person vs. $13 213/person). Based on multivariable analysis, while men who underwent XRT had a lower relative cost in their first year after treatment (relative rate [RR] 0.97; 95% confidence interval [CI] 0.94-1.0; p=0.025), after year 2, annual costs were significantly higher in the radiation group compared to the surgery group (total cost for year 5, RR 1.44; 95% CI 1.17-1.76; p<0.0001). Our results were similar when restricted to young, healthy men and to older men.

CONCLUSIONS

Men who undergo radiation have significantly higher five-year total treatment-related costs compared to men who undergo open radical prostatectomy. While surgery was associated with slightly higher initial costs, radiotherapy had higher costs in subsequent years.

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

BACKGROUND

Readmission to acute care is common and is associated with indicators of suboptimal care and health system inefficiencies. The objective of this study was to identify independent determinants of readmission following survival of hypoxic ischemic brain injury.

METHODS

We conducted a population-based retrospective cohort study using Ontario's administrative health data. Survivors of hypoxic ischemic brain injury aged 20 years or more discharged from acute care between fiscal years 2002/03 and 2010/11 were included. Multivariable negative binomial regression was used to identify independent determinants of both number of readmissions and cumulative duration of hospital stay(s) within 1 year after the index discharge.

RESULTS

Of the 593 patients with hypoxic ischemic brain injury, 233 (39.3%) were readmitted within 1 year of the index acute care discharge. The number of readmissions was associated with age (35-49 yr v. 65-79 yr: rate ratio [RR] 0.57, 95% confidence interval [CI] 0.38-0.85; ≥ 80 yr v. 65-79 yr: RR 0.58, 95% CI 0.34-0.97) and higher comorbidity score (Johns Hopkins Aggregated Diagnosis Groups score > 30 v. < 10: RR 1.60, 95% CI 1.11-2.31). Cumulative readmission stay was associated with increased index acute care length of stay (31-90 d v. ≥ 90 d: RR 4.17, 95% CI 1.38-12.64), prior use of health care services (minimal v. very high: RR 0.15, 95% CI 0.05-0.49) and discharge disposition (home v. continuing/long-term care: RR 0.44, 95% CI 0.21-0.91).

INTERPRETATION

The findings indicate a high readmission rate in the first year after the index acute care admission for survivors of hypoxic ischemic brain injury, reflecting care gaps and system inefficiencies. This suggests that bolstered discharge and home care planning and support are needed to address the specific needs of those with hypoxic ischemic brain injury.

Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study

BACKGROUND

Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU).

METHODS

We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate.

RESULTS

In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071).

CONCLUSION

Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.

Medical Costs of Delayed Hip Fracture Surgery

BACKGROUND

Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs.

METHODS

We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days).

RESULTS

The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours.

CONCLUSIONS

Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery.

LEVEL OF EVIDENCE

Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.

Systematic review of rehabilitation intervention outcomes of adult and paediatric patients with infectious encephalitis

OBJECTIVE

Although a range of rehabilitation interventions have been applied to restore function after infectious encephalitis, there is a lack of literature summarising the benefits of these interventions. This systematic review aims to synthesise current scientific knowledge on outcome measures following rehabilitative interventions among children and adults with infectious encephalitis, with a specific focus on the influence of the age, sex, baseline status and intervention type.

SEARCH STRATEGY

Five scholarly databases (MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials), three sources of grey literature (Google, Google Scholar and Grey Matters) and reference lists of included publications were systematically searched. Literature published before 15 December 2017 and focused on patients with infectious encephalitis in any rehabilitation setting were included. Quality assessment was completed using the Downs and Black rating scale.

RESULTS

Of the 12 737 reference titles screened, 20 studies were included in this review. All of the studies had sample sizes of less than 25 patients and received a score of less than 15 out of 31 points on the Downs and Black rating scale. Findings showed a variety of interventions has been applied to alleviate sequelae from infectious encephalitis, including using cognitive therapy (nine studies), behavioural therapy (five studies), physical therapy (two studies) or two or more therapies (four studies). There was inconclusive evidence on the effect of sex, age and baseline functional abilities on outcomes. Due to clinical and methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSION

Evidence suggests the potential for a beneficial effect of rehabilitation interventions in patients with infectious encephalitis. Future research is required to identify all effect modifiers and to determine the effect of time in the natural course of recovery. An enhanced set of known effect modifiers will support the process of future evaluation of a client-centred rehabilitation intervention.

TRIAL REGISTRATION NUMBER

CRD42015029217.

Interrater Reliability of Three Versions of the Chedoke Arm and Hand Activity Inventory

Purpose: The purpose of this study was to estimate the interrater reliability of three shortened versions of the Chedoke Arm and Hand Activity Inventory (CAHAI-7, CAHAI-8, CAHAI-9) when used with persons with acquired brain injury (ABI). The CAHAI is an assessment of upper limb function with high reliability in the stroke and ABI populations. In the stroke population, three shortened versions of the measure have established reliability. Clinicians report time constraints as a barrier to using standardized assessments; thus, establishing the reliability of the shortened versions of the CAHAI in the ABI population may increase the use of this measure. Method: This was an observational, parameter estimation study. The participants were recruited from an in-patient ABI rehabilitation programme. The administration of the CAHAI to six persons with ABI was video recorded, and the video recordings were assessed by six clinicians to estimate interrater reliability. A Latin square design was used to balance the order in which the raters evaluated the videos. A repeated-measures analysis of variance was performed, and the variance components were used to calculate an intra-class correlation coefficient (ICC) and standard error of measurement (SEM) with 95% confidence limits (CLs) for each of the shortened versions. Results: Interrater reliability was high for all three versions: CAHAI-7, ICC=0.96 (95% CL: 0.89, 0.99; SEM 2.65); CAHAI-8, ICC=0.96 (95% CL: 0.90, 0.99; SEM 2.72); and CAHAI-9, ICC=0.95 (95% CL: 0.85, 0.99; SEM 3.49). Conclusions: These results suggest that the three shortened versions of the CAHAI demonstrate high reliability in the ABI population. These versions may be particularly useful when time constraints or patient tolerance are an issue.

Hospital Mortality Among Elderly Patients Admitted With Neurological Disorders Was Not Predicted by any Particular Diagnosis in a Tertiary Medical Center

Background:

Neurological disorders (NDs) are associated with high hospital mortality. We aimed to identify predictors of hospital mortality among elderly inpatients with NDs.

Methods:

Patients aged ≥60 years admitted to the hospital between January 1, 2009 and December 31, 2010 with acute NDs, chronic NDs as underpinnings of acute clinical disorders, and neurological complications of other diseases were studied. We analyzed demographic data, NDs, and comorbidities as independent predictors of hospital mortality. Logistic regression was performed for multivariable analysis.

Results:

Overall, 1540 NDs and 2679 comorbidities were identified among 798 inpatients aged ≥ 60 years (mean 75.8±9.1). Of these, 54.5% were female. Diagnostic frequency of NDs ranged between 0.3% and 50.8%. Diagnostic frequency of comorbidities ranged from 5.6% to 84.5%. Comorbidities varied from 0 to 9 per patient (90% of patients had ≥2 comorbidities), mean 3.2±1.47(CI, 3.1-3.3). Patients with multimorbidities presented with a mean of 4.7±1.7 morbidities per patient. Each ND and comorbidity were associated with high hospital mortality, producing narrow ranges between the lowest and highest incidences of death (hospital mortality = 18%) (95% CI, 15%-21%). After multivariable analysis, advanced age (P<0.001) and low socioeconomic status (P=0.003) were recognized as predictors of mortality, totaling 9% of the variables associated with hospital mortality.

Conclusion:

Neither a particular ND nor an individual comorbidity predicted hospital mortality. Age and low socioeconomic class accounted for 9% of predictors. We suggest evaluating whether functional, cognitive, or comorbidity scores will improve the risk model of hospital mortality in elderly patients admitted with ND.

Direct medical costs of motorcycle crashes in Ontario

BACKGROUND

There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes.

METHODS

We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach.

RESULTS

We identified 26 831 patients injured in motorcycle crashes and 281 826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale ≥ 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100 000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001).

INTERPRETATION

Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety.

A Systematic Review of Comorbidity Measurement Methods for Patients With Nontraumatic Brain Injury in Inpatient Rehabilitation Settings

This review summarizes comorbidity measurements used on patients with nontraumatic brain injury in inpatient rehabilitation and describes findings on measurement validation and comorbidity profiles. MEDLINE and MEDLINE In-Process, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews, Health, and Psychosocial Measurement Instruments were searched. Two reviewers screened results according to predefined inclusion and exclusion criteria. Population, statistical methods, comorbidity measurement, justification of its use, and results involving comorbidity were extracted using a standard table. Of 9476 articles retrieved, 16 were included. Comorbidity has been measured using various methods including the following: number and type within various classification systems, such as the International Disease Classification system, the Charlson comorbidity index, Centers for Medicare and Medicaid Services comorbidity tiers and patient comorbidity and complexity level values and subsets of diagnoses within nonadministrative data studies. No studies have assessed the predictive ability of the comorbidity measurements for inpatient rehabilitation outcomes in this population. Because comorbidities are common among the nontraumatic brain injury population, the predictive validity of comorbidity measurements should be assessed to determine the most appropriate measure to predict or risk adjust rehabilitation outcomes, which has implications for the development of clinical guidelines, and to inform health service research, planning, and delivery.

Incidence and mortality of acquired brain injury in young Danish adults between 1994 and 2013: a nationwide study

BACKGROUND

We estimated the annually incidence and mortality of acquired brain injury (ABI) in people aged 15-30 years during 1994-2013.

METHODS

All Danes with a first-ever hospital diagnosis of ABI, including traumatic brain injury (TBI), encephalopathy, CNS-infection or brain tumour, were identified in the Danish National Patient Register. Incidence rates (IRs) and estimated annual percentage changes (EAPC) were estimated by Poisson regression. Mortality was estimated by the Kaplan-Meier estimator and adjusted hazard ratios (aHR) were computed using Cox regression with 1994-1998.

RESULTS

A total of 10,542 individuals were hospitalized with a first-time diagnosis of ABI. The IR for ABI decreased from 63.36 to 33.91/100,000 person-years from 1994 to 2013 [EAPC: -2.78% (95% CI: -3.26 to -2.28)] mainly driven by a decreasing IR of TBI [EAPC: -6.53% (95% CI: -9.57 to -3.39)] during 2007-2013. IRs of brain tumour and CNS infections also decreased significantly. The mortality after ABI tended to be higher during 1999-2013 compared to 1994-1998. For brain tumour, the 1-year mortality decreased significantly [2009-2013 aHR: 0.41 (95% CI: 0.23-0.72)].

CONCLUSION

Incidence of hospitalisations for ABI and in particular TBI has decreased significantly. Overall, the mortality after ABI has not improved, but the mortality after brain tumour has decreased significantly.

The Relationship Between Traumatic Injury in Children and Long-Term Use of Health and Social Services by Children and Their Families

To increase understanding of relationships between general traumatic injury in children and long-term use of resources in the health care and social services (HSS) sectors by these children and their families 8-10 years after traumatic injury. This study was a cross-sectional retrospective cohort study of prognosis from 2001 to 2003 that quantified recent expenditures on and use of HSS by children and also by their parents. Forty-eight cases of children were selected from the Hamilton Health Sciences pediatric trauma database in the period from January 2001 to December 2003 after incurring a traumatic injury with Injury Severity Score greater than 12. The average total cost to the HSS system per child's family was $4,326.62 during the preceding 6 months. During the same period, average use of HSS was 7 visits. Total service costs incurred by caregivers of injured children increased with severity of the traumatic injury (p= .009). Caregiver HSS use was higher when the injury was caused by a motor vehicle accident than by other types of accidents (p< .001) and increased with the injury severity (p< .001). HSS use by children was related to gender (p< .001), injury mechanism (p< .001), age at accident (p< .001), and time since accident (p= .012), among other factors. Pediatric trauma appears to have long-term effects on expenditures on and use of HSS by the affected children and their families. The findings emphasize the need for long-term assessment and possible delivery of services to the families of the injured children.

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

INTRODUCTION

Many studies have assessed the predictors of morbidity/mortality of patients with traumatic brain injury (TBI) in acute care. However, with the increasing rate of survival after TBI, more attention has been given to discharge destinations from acute care as an important measure of clinical priorities. This study describes the design of a systematic review compiling and synthesising studies on the prognostic factors of discharge settings from acute care in patients with TBI.

METHODS AND ANALYSIS

This systematic review will be conducted on peer-reviewed studies using seven databases including Medline/Medline in-Process, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, PsycINFO, CINAHL and Supplemental PubMed. The reference list of selected articles and Google Scholar will also be reviewed to determine other relevant articles. This study will include all English language observational studies that focus on adult patients with TBI in acute care settings. The quality of articles will be assessed by the Quality in Prognostic Studies tool.

ETHICS AND DISSEMINATION

The results of this review will provide evidence that may guide healthcare providers in making more informed and timely discharge decisions to the next level of care for patient with TBI. Also, this study will provide valuable information to address the gaps in knowledge for future research.

TRIAL REGISTRATION NUMBER

Trial registration number (PROSPERO) is CRD42016033046.

Evaluation of the Cost of Comprehensive Outpatient Therapies in Patients with Malignant Brain Tumors

OBJECTIVE

The aim of this study was to compare the cost of comprehensive outpatient therapy (day rehabilitation) in individuals with malignant brain tumors to those with stroke and traumatic brain injury.

DESIGN

This was a prospective, nonrandomized, longitudinal study of 49 consecutive adults with malignant brain tumors enrolled in the 6 day rehabilitation sites of 1 institution over 35 months. The control group was composed of 50 patients with brain injury and 50 patients with stroke, who were also enrolled in the day rehabilitation program during the same period. A comparison was made of the total Medicare cost and the cost per day of day rehabilitation in patients with malignant brain tumors compared with the control group.

RESULTS

The patients with malignant brain tumors had lower total cost and cost per day than did the combined traumatic brain injury and stroke group during day rehabilitation (F2,143 = 3.056 [P = 0.05] and F2,142 = 5.046 [P = 0.008], respectively).

CONCLUSIONS

The cost of comprehensive outpatient rehabilitation in patients with malignant brain tumors is less expensive than that of patients with traumatic brain injury or stroke, which are neurological diagnoses commonly seen in day rehabilitation. This study shows that cost should not be a barrier to providing outpatient therapies to this patient population.