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Etemad LL, Yue JK, Barber J, Nelson LD, Bodien YG, Satris GG, Belton PJ, Madhok DY, Huie JR, Hamidi S, Tracey JX, Coskun BC, Wong JC, Yuh EL, Mukherjee P, Markowitz AJ, Huang MC, Tarapore PE, Robertson CS, Diaz-Arrastia R, Stein MB, Ferguson AR, Puccio AM, Okonkwo DO, Giacino JT, McCrea MA, Manley GT, Temkin NR, DiGiorgio AM. Longitudinal Recovery Following Repetitive Traumatic Brain Injury. JAMA Netw Open 2023; 6:e2335804. [PMID: 37751204 PMCID: PMC10523170 DOI: 10.1001/jamanetworkopen.2023.35804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023] Open
Abstract
Importance One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited. Objective To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years. Design, Setting, and Participants This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023. Exposures Postindex TBI(s). Main Outcomes and Measures Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs. Results Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains. Conclusions and Relevance In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.
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Affiliation(s)
- Leila L. Etemad
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - John K. Yue
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Jason Barber
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Yelena G. Bodien
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California, San Francisco
| | - J. Russell Huie
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Sabah Hamidi
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Joye X. Tracey
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Bukre C. Coskun
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Justin C. Wong
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Amy J. Markowitz
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Michael C. Huang
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | | | | | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego
| | - Adam R. Ferguson
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joseph T. Giacino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
- Department of Neurology, Medical College of Wisconsin, Milwaukee
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Nancy R. Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- Institute of Health Policy Studies, University of California, San Francisco
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Yue JK, Krishnan N, Chyall L, Vega P, Hamidi S, Etemad LL, Tracey JX, Tarapore PE, Huang MC, Manley GT, DiGiorgio AM. Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury. Injury 2023; 54:110815. [PMID: 37268533 DOI: 10.1016/j.injury.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/21/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Hospital length of stay (HLOS) after traumatic brain injury (TBI) is a metric of injury severity, resource utilization, and access to services. This study aimed to evaluate socioeconomic and clinical factors associated with prolonged HLOS after TBI. METHODS Retrospective data from adult hospitalized patients diagnosed with acute TBI at a US Level 1 trauma center between August 1, 2019 - April 1, 2022 were extracted from the electronic health record. HLOS was stratified by Tier (1: 1-74th percentile; 2: 75-84th; 3: 85-94th; 4: 95-99th). Demographic, socioeconomic, injury severity, and level-of-care factors were compared by HLOS. Multivariable logistic regressions evaluated associations between socioeconomic and clinical variables and prolonged HLOS, using multivariable odds ratios (mOR) and [95% confidence intervals]. Estimated daily charges were calculated for a subset of medically-stable inpatients awaiting placement. Statistical significance was assessed at p < 0.05. RESULTS In 1443 patients, median HLOS was 4 days (interquartile range 2-8; range 0-145). HLOS Tiers were 0-7, 8-13, 14-27, and ≥28 days (Tiers 1-4, respectively). Patients with Tier 4 HLOS differed significantly from others, with increased Medicaid insurance (53.4% vs. 30.3-33.1%, p = 0.003), severe TBI (Glasgow Coma Scale 3-8: 38.4% vs. 8.7-18.2%, p < 0.001), younger age (mean 52.3-years vs. 61.1-63.7-years, p = 0.003), low socioeconomic status (53.4% vs. 32.0-33.9%, p = 0.003), and need for post-acute care (60.3% vs. 11.2-39.7%, p < 0.001). Independent factors associated with prolonged (Tier 4) HLOS were Medicaid (mOR = 1.99 [1.08-3.68], vs. Medicare/commercial), moderate and severe TBI (mOR = 3.48 [1.61-7.56]; mOR = 4.43 [2.18-8.99], respectively, vs. mild TBI), and need for post-acute placement (mOR = 10.68 [5.74-19.89], while age was protective (per-year mOR = 0.98 [0.97-0.99]). Estimated daily charges for a medically-stable inpatient was $17126. CONCLUSIONS Medicaid insurance, moderate/severe TBI, and need for post-acute care were independently associated with prolonged HLOS ≥28 days. Medically-stable inpatients awaiting placement accrue immense daily healthcare costs. At-risk patients should be identified early, receive care transitions resources, and be prioritized for discharge coordination pathways.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America.
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Lawrence Chyall
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Paloma Vega
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Sabah Hamidi
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Leila L Etemad
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Joye X Tracey
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Phiroz E Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America; Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
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