Angela Colantonio

Factors associated with perceived quality of life many years after traumatic brain injury.

Objectives:To explore factors associated with perceived quality of life (QOL) 8 to 24 years after traumatic brain injury (TBI). Design:Retrospective cohort study. Participants:Two hundred seventy-five individuals who sustained moderate to severe TBI who were discharged from a rehabilitation hospital participated in this study. We interviewed consenting participants up to 24 years after injury. Outcome Measures:Self-rated Quality of Life Scale. Results:Multivariate linear regression analyses revealed that perceived mental health, self-rated health, gender (women rating QOL higher), participation in work and leisure, and the availability of emotional support were significantly associated with QOL (P < .05). Conclusion:The importance of designing ongoing support programs to further reintegrate TBI survivors several years after injury is discussed.

Long term outcomes after moderate to severe traumatic brain injury

Objective: This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI). Design: Retrospective cohort study. Setting and subjects: We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury. Main outcome measures: Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services. Results: Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living. Conclusion: Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.

Well-being after stroke in Canadian seniors: findings from the Canadian Study of Health and Aging.

Background and Purpose— After a stroke many people continue to live with their residual impairments and disabilities in the community, which can pose a significant problem for survivors’ well-being. The purpose of this research was to investigate patterns of well-being in community-dwelling stroke survivors to identify those factors that restrict and enhance well-being. Methods— A secondary analysis was conducted on data from the second wave of the Canadian Study of Health and Aging (CSHA-2). A national sample of 5395 community-dwelling Canadian seniors (aged ≥65 years) was interviewed for CSHA-2, including 339 stroke survivors (6.3%). Information was collected on health, social and demographic characteristics, and well-being. Comparisons were made between the health and functional status of stroke survivors and community-dwelling seniors who have not experienced a stroke. Multiple regression was used to examine the factors associated with well-being in stroke survivors. Results— Compared with community-dwelling seniors who have not experienced a stroke, stroke survivors report a lower sense of well-being. Stroke survivors are also more likely to be restricted in their physical and cognitive function, to report worse mental health, and to be living with a greater number of comorbid health conditions. Mental health and physical and cognitive disabilities are associated with a reduced sense of well-being in stroke survivors, but social supports and educational resources moderate the impact of functional status on well-being. Conclusions— Community-dwelling seniors who have had a stroke experience a reduced sense of well-being. However, social resources can help to alleviate the subjective burden of this common neurological condition.

The Pittsburgh sleep quality index as a screening tool for sleep dysfunction in clinical and non-clinical samples: A systematic review and meta-analysis

This review appraises the process of development and the measurement properties of the Pittsburgh sleep quality index (PSQI), gauging its potential as a screening tool for sleep dysfunction in non-clinical and clinical samples; it also compares non-clinical and clinical populations in terms of PSQI scores. MEDLINE, Embase, PsycINFO, and HAPI databases were searched. Critical appraisal of studies of measurement properties was performed using COSMIN. Of 37 reviewed studies, 22 examined construct validity, 19 - known-group validity, 15 - internal consistency, and three - test-retest reliability. Study quality ranged from poor to excellent, with the majority designated fair. Internal consistency, based on Cronbachs alpha, was good. Discrepancies were observed in factor analytic studies. In non-clinical and clinical samples with known differences in sleep quality, the PSQI global scores and all subscale scores, with the exception of sleep disturbance, differed significantly. The best evidence synthesis for the PSQI showed strong reliability and validity, and moderate structural validity in a variety of samples, suggesting the tool fulfills its intended utility. A taxonometric analysis can contribute to better understanding of sleep dysfunction as either a dichotomous or continuous construct.

The effect of traumatic brain injury on the health of homeless people

Background: We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario. Methods: We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004–2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions. Results: The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (–8.3 points, 95% CI –11.1 to –5.5) and poorer mental health status (–6.0 points, 95% CI –8.3 to –3.7). Interpretation: Prior traumatic brain injury is very common among homeless people and is associated with poorer health.

Head injury in young adults: long-term outcome☆☆☆

OBJECTIVE To describe the long-term outcome 5 years after injury of young adults who were 15 to 19 years old at the time of their head injuries. DESIGN A retrospective cohort. The health records of 62 consecutive eligible subjects were abstracted for baseline sociodemographic, health, and injury variables. A telephone interview was administered to assess quality of life, impairment, disability, and handicap. SETTING Canadas largest trauma center, Sunnybrook Health Science Centre, Toronto, Canada. SUBJECTS Of the 58 subjects (94%) who were traced at follow-up, 51 agreed to participate. MAIN OUTCOME MEASURES The Medical Outcomes Study SF-36, Head Injury Symptom Checklist, selected disability measures, Community Integration Questionnaire. RESULTS Of the 8 summary items of the Medical Outcomes Study SF-36, subjects scored lowest on mental health. There were no significant differences between mild and more severely injured groups in all quality of life measures. Subjects classified with mild head injury overall reported more symptoms from the Head Injury Symptom Checklist. Subjects with more severe injuries had lower community integration scores (p < .05). CONCLUSIONS Overall, mental health is an important area of concern at follow-up for all subjects. Adolescents with apparent mild head injury can have disabling symptoms many years after injury.

Mild traumatic brain injury from motor vehicle accidents: Factors associated with return to work

OBJECTIVES To describe return to work (RTW) for motor vehicle accident (MVA) survivors with mild traumatic brain injury (MTBI) and to examine relationships between RTW and injury severity, cognitive impairment, social interaction, discharge disposition, and sociodemographics. DESIGN Inception cohort assessed within 1 month of injury and at follow-up 6 to 9 months (mean = 7.4) after injury, for comparisons on outcome of RTW. SETTING Tertiary care center in Toronto (time 1); at home for follow-up. PARTICIPANTS Fifty patients with MTBI resulting from MVA who were consecutively admitted during a 20-month period ending April 1994. Thirteen of 63 eligible patients refused consent or were lost to follow-up. Mean age was 31; 62% were men. ELIGIBILITY CRITERIA (1) patients had been working; (2) they had no history of head injury, neurologic disease, or psychiatric illness requiring hospitalization; and (3) they had no catastrophic impairment from accident. MAIN OUTCOME MEASURE Return to work (at premorbid or modified level). RESULTS Of the 42% who returned to work, 12% resumed their premorbid level of employment and 30% returned to modified work. There were significant differences (p<.05) between the groups in level of social interaction, premorbid occupation, and discharge disposition. On one test of cognitive functioning the difference was at p = .06. CONCLUSION Social interaction, jobs with greater decision-making latitude, and discharge home were positively related to RTW for this population. Cognitive impairment within the first month was not a reliable indicator of RTW potential.

Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability‐a population perspective

BACKGROUND There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was to compare hospitalisation rates for ambulatory care sensitive conditions between persons with and without an ID in a publicly insured population. METHODS Persons with an ID were identified among the general population of a Canadian province between 1999 and 2003. Using a list of conditions applicable to persons with an ID, rates of hospitalisations for ambulatory care sensitive conditions for persons with and without an ID were calculated and compared. Regression models were used to adjust for age, sex and place of residence. Hospitalisation rates for specific conditions were also compared, controlling for differences in disease prevalence where possible. RESULTS Persons with an ID were consistently hospitalised for ambulatory care sensitive conditions at a higher rate than persons without an ID. Between 1999 and 2003 the adjusted rate ratio (RR) was 6.1 [95% confidence interval (CI) = 5.6, 6.7]. Rate ratios were highest when comparing persons with, to persons without, an ID between the ages of 30-39 (RR = 13.1; 95% CI = 10.6, 16.2) and among urban area dwellers (RR = 7.0; 95% CI = 6.2, 7.9). Hospitalisation rates for epilepsy and schizophrenic disorders were, respectively, 54 and 15 times higher for persons with compared with persons without an ID. Rate ratios for diabetes and asthma remained significant after controlling for the population prevalence of these diseases. CONCLUSIONS The large discrepancy in rates of hospitalisation between persons with and without an ID is an indicator of inadequate primary care for this vulnerable population. Decreasing the number of ambulatory care sensitive condition hospitalisations through specialised outpatient programmes for persons with an ID would potentially lead to better health, improved quality of life and cost savings. Future research should include potentially important factors such as disease severity, socio-economic variables and measures of health service organisation in the analysis. International comparisons of ambulatory care sensitive condition hospitalisation rates could point to the benefits and limitations of the health service policy directions adopted by different countries.

Early Identification and Incidence of Mild TBI in Ontario

OBJECTIVES (1) To examine the variability in diagnosis of mild traumatic brain injury (mTBI) in primary care relative to that of an expert reviewer; and (2) to determine the incidence rate of mTBI in Ontario, Canada. METHOD Potential mTBI cases were identified through reviewing three months of Emergency Department (ED) and Family Physician (FP) health records. Potential cases were selected from ED records using the International Classification of Disease, 9th revision, Clinical Modification and External Cause codes and from all FPs records for the time period. Documented diagnoses of mTBI were compared to expert reviewer diagnosis. Incidence of mTBI was determined using the documented diagnoses and data from hospital catchment areas and population census. RESULTS 876 potential mTBI cases were identified, 25 from FP records. Key indicators of mTBI were missing on many records (e.g., 308/876 records had Glasgow Coma Scale (GCS) scores). The expert reviewer disagreed with the documented diagnosis in 380/876 cases (kappa = 0.19). The expert reviewer was more likely to give a diagnosis if the GCS was 13-14, if there was documented loss of consciousness and/or post-traumatic amnesia, and/or if there was pathology found on an acute brain scan. Calculated incidence rates of hospital-treated mTBI were 426 or 535/100,000 (expert review--hospital diagnosis). Including family physician cases increased the rate to 493 or 653/100,000. CONCLUSION Health record documentation of key indicators for mTBI is often lacking. Notwithstanding, some patients with mTBI appear to be missed or misdiagnosed by primary care physicians. A more comprehensive case definition resulted in estimated incidence rates higher than previous reports.

Hospitalizations and emergency department visits for TBI in Ontario.

OBJECTIVE The aim of this study was to determine the number of annual hospitalizations and overall episodes of care that involve a traumatic brain injury (TBI) by age and gender in the province of Ontario. To provide a more accurate assessment of the prevalence of TBI, episodes of care included visits to the emergency department (ED), as well as admissions to hospital. Mechanisms of injury for overall episodes were also investigated. METHODS Traumatic brain injury cases from fiscal years 2002/03-2006/07 were identified by means of ICD-10 codes. Data were collected from the National Ambulatory Care Reporting System and the Discharge Abstract Database. RESULTS The rate of hospitalization was highest for elderly persons over 75 years-of-age. Males generally had higher rates for both hospitalizations and episodes of care than did females. The inclusion of ED visits to hospitalizations had the greatest impact on the rates of TBI in the youngest age groups. Episodes of care for TBI were greatest in youth under the age of 14 and elderly over the age of 85. Falls (41.6%) and being struck by or against an object (31.1%) were the most frequent causes for a TBI. CONCLUSIONS The study provides estimates for TBI from the only Canadian province that has systematically captured ED visits in a national registry. It shows the importance of tracking ED visits, in addition to hospitalizations, to capture the burden of TBI on the health care system. Prevention strategies should include information on ED visits, particularly for those at younger ages.