Jennifer H. Marwitz

Etiology and incidence of rehospitalization after traumatic brain injury: A multicenter analysis

OBJECTIVE To investigate incidence and etiology of rehospitalizations at 1, 2, and 3 years after traumatic brain injury. DESIGN Descriptive statistics were computed in a prospective study of etiology and incidence of rehospitalization at years 1, 2, and 3 postinjury. Analysis of variance (ANOVA) and chi2 were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics. SETTING Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS Six hundred sixty-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1996. MAIN OUTCOME MEASURES Annual incidence and etiology of rehospitalization. RESULTS The annual incidence of rehospitalization ranged from 20% to 22.5%. Approximately half the rehospitalizations were for elective reasons. The most common reason for rehospitalization was for orthopedic or reconstructive surgery, followed by infectious disorders and general health maintenance. After the first year, the incidence of readmissions for seizures and psychiatric difficulties increased substantially. ANOVA and chi2 analyses were performed on data from the first year postinjury. No statistically significant associations were noted between incidence and etiology of rehospitalization and: demographics; injury severity; payer source for rehabilitation; concurrent injuries; acute care and rehabilitation length of stays; discharge Functional Assessment Measure; and discharge residence (p > .05). CONCLUSIONS There is a relatively stable but high rate of rehospitalization for at least 3 years after injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Moderating factors in return to work and job stability after traumatic brain injury

Objective:To examine job stability moderating variables and develop a postinjury work stability prediction model. Design:Multicenter analysis of individuals with traumatic brain injury (TBI) who returned for follow-up at 1, 2, and 3, or 4 years postinjury, were of working age (between 18 and 62 years of age at injury), and were working preinjury. Setting:Six National Institute on Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care. Participants:A total of 186 adults with TBI were included in the study. Main outcome measures:Job stability was categorized as stably employed (employed at all 3 follow-up intervals); unstably employed (employed at one or two of all three follow-up intervals); and unemployed (unemployed at all three follow-up intervals). Results:After injury, 34% were stably employed, 27% were unstably employed, and 39% were unemployed at all three follow-up intervals. Minority group members, people who did not complete high school, and unmarried people were more likely to be unemployed. Driving independence was highly influential and significantly related to employment stability. A discriminant function analysis, which included age, length of unconsciousness and Disability Rating Scale scores at 1 year postinjury, accurately predicted job stability groupings. ConclusionData analysis provided evidence that employment stability is predictable with a combination of functional, demographic, and injury severity variables. Identification of people at risk for poor employment outcomes early on can facilitate rehabilitation planning and intervention.

Functional outcomes of older adults with traumatic brain injury: A prospective, multicenter analysis☆

OBJECTIVE To investigate improvement rates and medical services costs in older brain injured adults relative to younger patients. DESIGN Descriptive statistics were computed in a prospective comparative study of 50 patients 55 years and older and 50 patients 18 to 54 years old matched for gender and injury severity (number of days in coma, admission Glasgow Coma Score, intracranial pressure). Independent t tests were performed to examine differences between the two samples on specific variables. SETTING Five medical centers in the federally sponsored Traumatic Brain Injury Model Systems Project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS Patients were selected from a national database of 531 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury between 1989 and 1994. MAIN OUTCOME MEASURES Disability Rating Scale, Functional Independence Measure, Rancho Los Amigos Levels of Cognitive Functioning Scale, length of stay, acute care and rehabilitation charges, and discharge disposition. RESULTS Older persons averaged a significantly longer rehabilitation length of stay, higher total rehabilitation charges, and a lower rate of change on functional measures. No significant differences between groups were found for acute care length of stay, daily rehabilitation charges, acute care charges (daily or total), or discharge disposition. CONCLUSIONS Although older persons demonstrated functional changes, the cost of change was substantially higher than for younger patients, coincident with longer lengths of stay. These higher overall charges and slower rates of change may effect changes in referral and management patterns.

A preliminary investigation of the brain injury family intervention: Impact on family members

Primary objective: To evaluate the benefits of the Brain Injury Family Intervention (BIFI) for families of persons with acquired brain injury and identify factors related to outcomes. Research design: Pre-test, post-test design with outcomes measured immediately after and 3 months following intervention. Methods and procedures: Family members and survivors participated in five 2-hour sessions over 10 weeks which included discussions of typical effects of brain injury, coping with loss and change, managing stress and intense emotions, effective problem-solving, setting reasonable goals and taking care of ones self. Guided by principles of family systems theory (FST) and cognitive behaviour therapy (CBT), the manualized treatment included educational, skill building and psychological support components. Main outcomes and results: Analysis of data derived from family members indicated a greater number of met needs and perceptions of fewer obstacles to receiving services post-treatment and at 3 months follow-up. Before and after treatment, unmarried caregivers reported more unmet needs. Family members of persons with longer acute care lengths of stay reported more unmet needs and greater perceived obstacles to services. Post-treatment differences in family members’ psychological distress, satisfaction with life and functioning were not identified. Conclusions: The investigation provided evidence that family members benefit from interventions designed to meet their unique needs after brain injury. Uncertainties remain about the benefits of intervention to general family functioning and life satisfaction.

Interrelationships between crime, substance abuse, and aggressive behaviours among persons with traumatic brain injury.

Professionals have suggested that aggressiveness, substance abuse, and criminality contribute to poor outcomes after brain injury. There is considerable research regarding post-injury aggressive behaviour, but limited information concerning criminal behaviour and alcohol use patterns. With a sample of 327 patients varying in severity of traumatic brain injury, the present investigation examined alcohol use patterns, arrest histories, behavioural characteristics, and psychiatric treatment histories. Relative to the uninjured population, analysis revealed relatively high incidence of heavy drinking, both pre- and post-injury, among patients with a history of arrest. Increases in abstinence rates were found regardless of arrest history. In addition, a history of arrest was associated with a greater likelihood of psychiatric treatment. Findings also indicated relatively high levels of aggressive behaviours. Discussion focuses on implications for evaluation, rehabilitation, and future research.

The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: a multicenter analysis.

OBJECTIVES To identify factors relating to the intensity of rehabilitation services received and to ascertain the relation between injury outcomes, demographics, types of therapy, and the intensity of rehabilitation services provided. DESIGN A multicenter, prospective, nonrandomized study with inpatient rehabilitation data collected between 1989 and 1996. SETTING Three medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, and inpatient rehabilitation. PARTICIPANTS A total of 491 consecutively enrolled patients with a mean age +/- standard deviation of 34.3+/-15.88 years recruited from 3 medical centers. To be included in the study, patients must have been at least 16 years of age, have presented to the emergency department within 24 hours of injury, and have received acute care and inpatient rehabilitation. INTERVENTIONS Patients received comprehensive medical care along with a combination of rehabilitative therapies, including physical, occupational, psychologic, and speech therapy. MAIN OUTCOME MEASURES Therapy intensity; levels of functional independence, cognitive function, functional gain, and treatment efficiency, as indicated by the FIM instrument; rehabilitation length of stay (LOS); and charges. RESULTS Age predicted the intensity of both psychologic (P<.001) and total therapy (P<.01) services. Acute care LOS was also a significant predictor of psychologic services (P<.01). Only admission motor FIM was relevant in predicting speech services intensity (P<.01). Therapy intensity was predictive of motor functioning at discharge (P<.001). However, therapy intensity did not predict cognitive gain (P<.05). CONCLUSIONS This study is among the first multicenter efforts to examine the potential benefits of individual therapy services. Findings support assertions that increased therapy intensity, particularly physical and psychologic therapies, enhances functional outcomes.

Alcohol and Drug Use Among Young Persons with Traumatic Brain Injury

The pre- and postinjury patterns of alcohol and illicit drug use of 87 persons with traumatic brain injury ages 16 to 20 were examined. Follow-up data were collected at two time intervals averaging 8 and 28 months postinjury. A comparison with large-sample studies revealed that patients had preinjury drinking patterns similar to those in the general population. A review of data provided evidence of a decline in alcohol use at initial follow-up; however, preinjury and second follow-up alcohol use patterns were similar. Analyses suggested that drinking quantity and frequency increased over time, perhaps eventually returning to postinjury levels. A review of the literature and the findings of the present investigation indicate that men and persons with a history of preinjury heavy drinking are at greatest risk for long-term alcohol abuse postinjury. Postinjury illicit drug use rates remained relatively low, falling below 10% at both follow-up intervals. Among persons taking prescribed medications, 17% reported moderate or heavy drinking at second follow-up.

A multicentre study on the clinical utility of post-traumatic amnesia duration in predicting global outcome after moderate-severe traumatic brain injury

Background: Past research shows that post-traumatic amnesia (PTA) duration is a particularly robust traumatic brain injury (TBI) outcome predictor, but low specificity limits its clinical utility. Objectives: The current study assessed the relationship between PTA duration and probability thresholds for Glasgow Outcome Scale (GOS) levels. Methods: Data were prospectively collected in this multicentre observational study. The cohort was a consecutive sample of rehabilitation patients enrolled in the National Institute on Disability and Rehabilitation Research funded TBI Model Systems (n = 1332) that had documented finite PTA duration greater than 24 h, and 1-year and 2-year GOS. Results: The cohort had proportionally more Good Recovery (44% vs 39%) and less Severe Disability (19% vs 23%) at year 2 than at year 1. Longer PTA resulted in an incremental decline in probability of Good Recovery and a corresponding increase in probability of Severe Disability. When PTA ended within 4 weeks, Severe Disability was unlikely (<15% chance) at year 1, and Good Recovery was the most likely GOS at year 2. When PTA lasted beyond 8 weeks, Good Recovery was highly unlikely (<10% chance) at year 1, and Severe Disability was equal to or more likely than Moderate Disability at year 2. Conclusions: Two PTA durations, 4 weeks and 8 weeks, emerged as particularly salient GOS probability thresholds that may aid prognostication after TBI.

Gender differences in executive functions following traumatic brain injury

The present study used the National Institute on Disability Rehabilitation and Research (NIDRR) funded Traumatic Brain Injury Model Systems (TBIMS) database to examine the effect of gender on presentation of executive dysfunction following traumatic brain injury (TBI) and variables that might impact the course and degree of recovery. The Wisconsin Card Sort Test (WCST) was chosen as a measure of executive function which has good credentials without reports of gender effects. Female subjects performed significantly better on the WCST than male subjects as shown by analyses of variance on scores of 1,331 patients for Categories Achieved (means for females = 4.09, males = 3.67, p = .003) and Perseverative Responses (means for females = 32.17, males = 36.42, p = .003). Outperformance by females was also noted in additional ANOVAs examining the interaction of education and gender, and ethnicity and gender in relation to Categories Achieved (p < .01), and for ethnicity and gender in relation to Perseverative Responses (p < .01). A multiple logistic regression revealed that gender, minority status, education level, history of illicit drug use, cause of injury, and length of coma each contributed uniquely to predicting Categories Achieved on the WCST. Simple logistic regression analyses showed that, of these variables, gender and cause of injury (violent vs. non-violent) were the strongest predictors. In contrast, when examining Perseverative Responses, regression analyses found gender, minority status and length of coma predicted impairment. Simple logistic regression analyses showed that, of these three variables, gender and minority status were most robust in predicting impaired Perseverative Responses scores. Implications of these findings are discussed and recommendations for further research are offered.

A multi-center analysis of rehospitalizations five years after brain injury.

Objective:To investigate the incidence and cause of rehospitalizations 1 and 5 years after traumatic brain injury. Design:Descriptive statistics were computed in a prospective study of the cause and incidence of rehospitalizations at years 1 and 5 after injury. Analysis of variance and chi-square tests were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics. Setting:Seventeen medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. Participants:Eight hundred ninety-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1999 were examined at 1-year follow-up. Main Outcome Measures:Incidence and cause of rehospitalization at 1 and 5 years after injury. Results:The incidence of rehospitalization ranged from 22.9% 1 year after injury to 17.0% at 5 years after injury. At 1 year after injury, a third of the rehospitalizations were for elective reasons. At 5 years after injury, the incidence of readmissions for seizures and psychiatric difficulties and general health maintenance increased substantially. T-tests and chi-square analyses were performed on the 5-year follow-up data to compare those rehospitalized for unplanned reasons with those not rehospitalized. Conclusions:There remains a relatively high rate of rehospitalization in the long term after traumatic brain injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.