Long-term medical care utilization and costs among traumatic brain injury survivors.

OBJECTIVE: To examine billing patterns and predictors of healthcare utilization and costs associated with traumatic brain injury. DESIGN: Retrospective cohort study of healthcare billings for 63 survivors of traumatic brain injury, over a 19-mo period, using a state-sponsored Medicaid program. The relationship of indicators of injury severity and disability to billings and payments was investigated. Mean age at time of injury was 33 yrs. Mean highest Glasgow Coma Scale rating immediately after brain injury was 8. RESULTS: A total of 795,635 US dollars was billed to Medicaid for 3,950 services and medications used. A total of 281,897 US dollars was paid for these billings out of the Medicaid account studied. Billings were used for statistical analyses, as they were considered the most stable indicator of cost. Motor deficits at discharge from inpatient rehabilitation (FIM motor score) showed inverse relationships to total billings (rho = -0.42, P < 0.001), subcategories of billings reflecting equipment and supplies (rho = -.26, P = 0.020), and outpatient billings (rho = -0.27, P = 0.015). Change in FIM motor scores during inpatient rehabilitation was inversely associated with billings (rho = -0.40). Change in FIM motor scores provided unique information in predicting utilization after accounting for demographic characteristics and severity of injury. CONCLUSIONS: Motor disability and improvement during inpatient rehabilitation were significant predictors of billings after traumatic brain injury. Initial severity of brain injury was not a significant factor in utilization.

Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Model Systems multicenter investigation.

OBJECTIVE: To identify the frequency and manifestations of depression after traumatic brain injury (TBI) and the factors that contribute to developing this mood disorder. DESIGN: A prospective, nationwide, multicenter study; 17 centers supplied data from medical records and patient responses on a standardized criterion instrument. SETTING: Traumatic Brain Injury Model Systems programs. PARTICIPANTS: A demographically diverse sample of 666 outpatients with TBI was evaluated 10 to 126 months after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Depressive symptoms were characterized with the Neurobehavioral Functioning Inventory by using the Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) diagnostic framework. Analysis of variance and Pearson correlations were used to identify factors that were significantly related to depression. RESULTS: Fatigue (29%), distractibility (28%), anger or irritability (28%), and rumination (25%) were the most commonly cited depressive symptoms in the sample. Twenty-seven percent of patients with TBI met the prerequisite number (>/=5) of criterion A symptoms for a DSM-IV diagnosis of major depressive disorder. Feeling hopeless, feeling worthless, and difficulty enjoying activities were the 3 symptoms that most differentiated depressed from nondepressed patients. Patients who were unemployed at the time of injury and who were impoverished were significantly more likely to report DSM-IV criterion A symptoms than patients who were employed, were students, or were retired due to age. Time after injury, injury severity, and postinjury marital status were not significantly related to depression. CONCLUSIONS: Patients with TBI are at great risk for developing depressive symptoms. Findings provide empirical support for the inclusion of depression evaluation and treatment protocols in brain injury programs. Unemployment and poverty may be substantial risk factors for the development of depressive symptoms. Future research should develop biopsychosocial predictive models to identify high-risk patients and examine the efficacy of treatment interventions.

The association of early computed tomography scan findings and ambulation, self-care, and supervision needs at rehabilitation discharge and at 1 year after traumatic brain injury.

OBJECTIVE: To ascertain the association between early computed tomography (CT) scan findings and the need for assistance with ambulation, activities of daily living (ADLs), and supervision at rehabilitation discharge and at 1 year after traumatic brain injury (TBI). DESIGN: Prospective longitudinal design. SETTING: Seventeen Traumatic Brain Injury Model Systems (TBIMS) centers. PARTICIPANTS: A total of 1,839 adults with TBI admitted to TBIMS trauma centers with subsequent acute rehabilitation; 849 were followed to 1 year after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Accumulated CT scan pathology from the first week after injury; FIM instrument and Disability Rating Scale at rehabilitation discharge and 1 year after injury; and Supervision Rating Scale at 1 year. RESULTS: Chi-square analyses showed that individuals with a midline shift greater than 5mm (lateral compression) were more likely to require the assistance of another person at discharge from acute rehabilitation with ambulation (29% vs 17%-19%, P=.02), toileting (47% vs 33%-38%, P=.05), lower-body dressing (57% vs 39%-46%, P=.015), bladder continence (32% vs 19%-23%, P=.03), and overall supervision (53% vs 44%, P=.0006) than patients with a midline shift of lesser degree. At 1 year, 57% of patients with a midline shift greater than 5mm on acute CT scans were being supervised in the home versus 30% to 39% of those with a shift of lesser degree (P=.003); there were no significant differences in the percentages of those needing assistance for ambulation or ADLs. The association of subdural hematoma with ambulation, self-care, and supervision needs was related to the degree of midline shift but not to the presence of subdural hematoma. Individuals with subcortical contusions were more likely to require assistance at rehabilitation discharge for ambulation (32% vs 18%, P<.0001), lower-body dressing (61% vs 44%), toileting (52% vs 35%), bladder continence (34% vs 22%), and overall supervision (61% vs 44%) than those without subcortical contusions (P<.0001). At 1 year, individuals with acute subcortical contusions were more likely to need assistance with ambulation (15% vs 8%, P=.004) and stair climbing (15% vs 9%, P=.03). Those with bilateral frontal (54% vs 46%, P=.009) or bilateral temporal (58% vs 46%, P=.03) contusions were more likely to need assistance with overall supervision at rehabilitation discharge, compared with those with unilateral or no cortical contusions. CONCLUSIONS: The presence of either a midline shift greater than 5mm or a subcortical contusion on acute CT scans is associated with a greater need of assistance with ambulation, ADLs, and global supervision at rehabilitation discharge. Patients with bilateral cortical contusions require more global supervision at rehabilitation discharge but no more supervision for ambulation and ADLs. These findings may aid health care professionals and potential caregivers in planning for rehabilitation and supervision needs after rehabilitation discharge and, to a lesser extent, at 1 year after TBI.

Blunt versus penetrating violent traumatic brain injury: frequency and factors associated with secondary conditions and complications.

OBJECTIVE: To compare types and frequency of medical complications and comorbidities associated with violence-related penetrating traumatic brain injury (TBI) as compared to violence-related blunt TBI. METHOD: Data were collected prospectively at four medical centers participating in the TBI Model Systems (TBIMS) of Care project. A total of 317 individuals met the inclusion criteria for the TBIMS (i.e., showed evidence of a TBI, were age 16 or older, presented to the TBIMS emergency department within 24 hours of injury, and received acute and rehabilitation services within the model system). MAIN OUTCOME MEASURES: Frequency of medical complications and comorbid diseases. RESULTS: Patients with penetrating injuries suffered significantly higher rates of respiratory failure (P =.004), pneumonitis/pneumonia, (P =.002), skull fracture (P =.001), cerebrospinal fluid leak (P =.0005), and hypotonia (P =.001) than did patients with blunt injuries. Prediction of complications and comorbidities via multiple regression revealed that a penetrating violent injury and the severity of injury were independent predictors of a higher rate of medical complications, whereas age and gender did not account for unique variance in the equation. CONCLUSIONS: Penetrating injuries are associated with higher rates of certain medical complications, especially to the pulmonary and central nervous systems. Acute care physicians and physiatrists must be prepared to treat these complications more often in patients with penetrating injuries.