Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review

Characterizing health care utilization following hospitalization for a traumatic brain injury: a retrospective cohort study

Objective: The purpose of this study was to characterize health services utilization among individuals hospitalized with a traumatic brain injury (TBI) 1-year post-injury.Methods: Using a retrospective cohort design, adult patients (n = 32, 042) hospitalized with a traumatic brain injury between 2005 and 2014 were selected from a statewide traumatic brain injury registry. Data on health services utilization for 1-year post-injury were extracted from electronic medical and administrative records. Descriptive statistics and logistic regression were used to characterize the cohort and a subgroup of superutilizers of health services.Results: One year after traumatic brain injury, 56% of participants used emergency department services, 80% received inpatient services, and 93% utilized outpatient health services. Superutilizers had ≥3 emergency department visits, ≥3 inpatient admissions, or ≥26 outpatient visits 1-year post-injury. Twenty-six percent of participants were superutilizers of emergency department services, 30% of inpatient services, and 26% of outpatient services. Superutilizers contributed to 81% of emergency department visits, 70% of inpatient visits, and 60% of outpatient visits. Factors associated with being a superutilizer included sex, race, residence, and insurance type.Conclusions: Several patient characteristics and demographic factors influenced patients' healthcare utilization post-TBI. Findings provide opportunities for developing targeted interventions to improve patients' health and traumatic brain injury-related healthcare delivery.

Soy diferente: a qualitative study on the perceptions of recovery following traumatic brain injury among Spanish-speaking U.S. immigrants

PURPOSE

To explore the impact of traumatic brain injury (TBI) on the quality of life (QoL) and self-concept of Spanish-speaking U.S. Hispanic immigrants with TBI.

MATERIALS AND METHODS

A prospective, qualitative study conducted in a county level I trauma center and community. Semi-structured interviews on QoL and self-concept following TBI were conducted with 24 Spanish-speaking U.S. Hispanic immigrants with TBI living in the community at least 6 months following injury.

RESULTS

Perceived facilitators of QoL included faith, hopefulness in recovery, empathy for others, and support from others. Perceived barriers to QoL mentioned were symptoms/consequences of injury, employment/financial changes, loss of independence, fear/uncertainty, stigma/shame, lack of medical care, and decreased social integration. Participants described their self-concept after TBI as either a maintained self or loss of self. Those who viewed themselves differently reported physical and emotional changes, gender role conflict, loss of self-worth, and total loss due to the TBI.

CONCLUSIONS

Spanish-speaking U.S. Hispanic immigrants held a strong faith and positive outlook after TBI in spite of the significant barriers to recovery. A need exists for programs to support creatively the recovery of Spanish-speaking U.S. Hispanic immigrants with limited access to care and resources.IMPLICATIONS FOR REHABILITATIONSpanish-speaking U.S. Hispanic immigrants may experience significant barriers to care following traumatic brain injury (TBI), such as access to rehabilitation services and follow-up care.Rehabilitation professionals should consider the importance of faith and encourage positive thinking and social support when working with Spanish-speaking U.S. Hispanic immigrants on how to cope with TBI-related challenges.Access to Spanish-speaking rehabilitation professionals, translators and Spanish language educational materials could help reduce language-related barriers to recovery among Spanish-speaking U.S. immigrants with TBI.Rehabilitation facilities should develop partnerships with community-based organizations serving the uninsured or underinsured to address the access to rehabilitation and medical needs of Spanish-speaking U.S. immigrants with TBI.

Integrated care pathways for Black persons with traumatic brain injury: a protocol for a critical transdisciplinary scoping review

BACKGROUND

Current understandings of the etiology of traumatic brain injury (TBI) and the trajectory of care significantly lack consideration for the inclusion of Black populations. The global prevalence of TBI is increasing, particularly in North America and Europe where approximately 65 million people are affected every year. Although community integration is an ultimate goal of rehabilitation post injury, persons with TBI, particularly Black populations continually face challenges with regards to unmet needs along the continuum of care including meaningful participation and vocation, resulting in occupational deprivation. While integrated care is seen as an appealing approach to service delivery, little is known about what this means for Black people with TBI. This protocol produces the first critical transdisciplinary (CTD) scoping review mapping the extent, range, and nature of integrated care pathways for Black people experiencing TBI.

METHODS

CTD provides an analytical tool with a health equity lens that will be applied as both a methodology and theory for undertaking this review. Under the methodological guidance of Arksey and O'Malley, CTD will be used to map the literature and better understand the elements of integrated care pathways for Black people experiencing TBI. To identify the published literature, several databases will be searched including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Sociological Abstracts.

DISCUSSION

The application of CTD compels health-care providers, administrators, clinician-scientists, rehabilitation specialists, and scholars in the field of TBI and integrated care to re-examine hidden assumptions about racism, racialization, and Blackness that are often embedded in current visions of health for all. The health equity lens of CTD asks about who is accounted for in the research and clinical literature and who is absented. It is anticipated that applying the health equity lens of CTD will provide a critical examination of the literature and illuminate significant implications for integrated care for Black persons experiencing TBI.

SYSTEMATIC REVIEW REGISTRATION

Not applicable.

Perceived health after adult traumatic brain injury: a Group-Based Trajectory Modeling (GBTM) analysis

OBJECTIVE

To provide nationally representative estimates of adults with traumatic brain injury (TBI) and identify clusters of individuals with TBI who follow similar perceived health trajectories using group-based trajectory modeling.

PARTICIPANTS

Adults (≥18 years old) from panels 9-19 (2004-2015) of the Medical Expenditure Panel Survey (MEPS) who experienced a TBI (n = 949).

DESIGN

Data from MEPS, a nationally representative database of noninstitutionalized individuals in the USA, were used to 1) produce a national annual estimate of adults with TBI and 2) identify subgroups of patients with TBI who followed different general and mental health trajectories.

MAIN MEASURES

Perceived general health (PGH), perceived mental health (PMH).

RESULTS

On average, 502 adults per 100,000 noninstitutionalized US adults experienced a TBI annually, and about one million adults are living with a TBI. Three distinct trajectory groups were identified in models of both perceived general health (PGH) and perceived mental health (PMH). TBI type, sex, and persistent disability predicted assignment to a group in the PGH model. TBI type, sex, age, insurance status, family poverty status, and persistent disability predicted assignment to a PMH trajectory.

CONCLUSION

Referrals and early-intervention resources should be distributed to individuals with increased risk of following low PGH and/or PMH trajectories.

Cohort Differences in Neurobehavioral Symptoms in Chronic Mild to Severe Traumatic Brain Injury

Our understanding of neurobehavioral symptoms after traumatic brain injury (TBI) largely relies on data gathered in studies conducted at academic medical centers or large clinical centers with research infrastructure. Though this often provides a well-characterized clinical sample, it may also introduce bias based on geographic locations served by these institutions and personal factors associated with patient access to these institutions. We collected neurobehavioral symptoms via the self-reported Behavioral Assessment Screening Tool (BAST) in a National TBI Cohort (n = 263) and a Medical Center TBI Cohort (n = 218) of English-speaking community-dwelling adults with chronic TBI. The primary focus of the present study was to compare demographics and neurobehavioral symptom reporting across the two cohorts and to discuss the implications of any such differences on interpretation of symptom scores. Across all BAST subscales (Negative Affect, Fatigue, Executive Function, Impulsivity, and Substance Abuse), participants in the National TBI Cohort reported significantly more frequent symptoms than those in the Medical Center TBI Cohort (p's < 0.001). Participants in the National TBI Cohort were more likely to be non-White and Hispanic compared to the Medical Center TBI Cohort, and those with mild TBI in the National TBI Cohort were more likely to have less than a high school education than those with mild TBI in the Medical Center TBI Cohort. Individuals with TBI recruited through academic and clinical institutions may not be representative of individuals with TBI living across the United States.

Neurobehavioral Symptoms in Community-Dwelling Adults With and Without Chronic Traumatic Brain Injury: Differences by Age, Gender, Education, and Health Condition

Neurobehavioral symptoms after Traumatic Brain Injury (TBI) are prevalent, persist for many years, and negatively affect long-term health, function, and quality of life. Symptoms may differ based on age, gender, education, race, ethnicity, and injury severity. To better understand neurobehavioral functioning after TBI, we need a comprehensive picture of emotional, cognitive, and behavioral symptoms in the context of personal factors that may affect these symptoms. We also need to understand the extent to which these symptoms are specific to TBI, shared across other neurological conditions, or attributable to factors outside of the injury itself. We collected neurobehavioral symptoms via the self-reported Behavioral Assessment Screening Tool (BAST) in a National Cohort of English (n = 2,511) and Spanish speaking (n = 350) community-dwelling adults with and without chronic TBI and other neurological and mental health conditions. The primary focus of the present study was to comprehensively describe neurobehavioral symptoms in adults with and without TBI, broken down by gender and health conditions and then further by age group or educational attainment. As expected, participants with TBI reported more symptoms than Healthy Controls. Regardless of condition, women reported more fatigue, while men reported more substance abuse and impulsivity. Hispanic participants reported more neurobehavioral symptoms than non-Hispanic participants did across health conditions, though primarily Spanish-speakers reported fewer symptoms than English-speakers, suggesting that level of acculturation may contribute to symptom reporting. These data provide a comprehensive characterization of neurobehavioral symptoms in adults with TBI and adults without TBI (healthy controls, adults with other neurological conditions, and adults with mental health conditions).

Early Endoscopy Is Associated with Better Clinical Outcomes in Patients Hospitalized with Ischemic Bowel Disease

BACKGROUND AND AIMS

Providing diagnostic and therapeutic interventions, lower gastrointestinal endoscopy is a salient investigative modality for ischemic bowel disease (IB). As studies on the role of endoscopic timing on the outcomes of IB are lacking, we sought to clarify this association.

METHODS

After identifying 18-to-90-year-old patients with a primary diagnosis of IB from the 2012-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we grouped them based on timing of endoscopy into three: early (n = 9268), late (n = 3515), and no endoscopy (n = 18,452). We explored the determinants of receiving early endoscopy, the impact of endoscopic timing on outcomes (mortality and 13 others), and the impact of the type of endoscopy (colonoscopy vs. sigmoidoscopy) on these outcomes among the early group (SAS 9.4).

RESULTS

Less likely to receive early endoscopy were Blacks compared to Whites (adjusted odds ratio [aOR] 0.81 95% CI [0.70-0.94]), and individuals on Medicaid, Medicare, and uninsured compared to the privately insured group (aOR 0.80 [0.71-0.91], 0.70 [0.58-0.84], and 0.68 [0.56-0.83]). Compared to the late and no endoscopy groups, patients with early endoscopy had less mortality (aOR 0.53 [0.35-0.80] and 0.09 [0.07-0.12]), shorter length of stay (LOS, 4.64 [4.43-4.87] days vs. 8.87 [8.40-9.37] and 6.62 [6.52-7.13] days), lower total hospital cost (THC, $41,055 [$37,995-$44,361] vs. $72,598 [$66,768-$78,937] and $68,737 [$64,028-$73,793]), and better outcomes. Similarly, among those who received early endoscopy, colonoscopy had better outcomes than sigmoidoscopy for mortality, THC, LOS, and adverse events.

CONCLUSION

Early endoscopy, especially colonoscopy, is associated with better clinical outcomes and decreased healthcare utilization in IB. Unfortunately, there are disparities against Blacks, and non-privately insured individuals in receiving early endoscopy.

Traumatic brain injury: sex, gender and intersecting vulnerabilities

Over the past decade, traumatic brain injury (TBI) has emerged as a major public health concern, attracting considerable interest from the scientific community, clinical and behavioural services and policymakers, owing to its rising prevalence, wide-ranging risk factors and substantial lifelong familial and societal impact. This increased attention to TBI has resulted in increased funding and advances in legislation. However, many questions surrounding TBI remain unanswered, including questions on sex and gender trends with respect to vulnerability to injury, presentation of injury, response to treatment, and outcomes. Here, we review recent research efforts aimed at advancing knowledge on the constructs of sex and gender and their respective influences in the context of TBI, and discuss methodological challenges in disentangling the differential impacts of these two constructs, particularly in marginalized populations.

Reimbursement for injury-induced medical expenses in Chinese social medical insurance schemes: A systematic analysis of legislative documents

Social medical insurance schemes are crucial for realizing universal health coverage and health equity. The aim of this study was to investigate whether and how reimbursement for injury-induced medical expenses is addressed in Chinese legislative documents relevant to social medical insurance. We retrieved legislative documents from the China National Knowledge Infrastructure and the Lawyee databases. Four types of social medical insurance schemes were included: urban employee basic medical insurance, urban resident basic medical insurance, new rural cooperative medical system, and urban and rural resident medical insurance. Text analyses were conducted on all identified legislative documents. As a result, one national law and 1,037 local legislative documents were identified. 1,012 of the 1,038 documents provided for reimbursement. Of the 1,012 documents, 828 (82%) provided reimbursement only for injuries without a legally responsible person/party or not caused by self-harm, alcohol use, drug use, or other law violations, and 162 (16%) did not include any details concerning implementation. Furthermore, 760 (92%) of the 828 did not provide an exception clause applying to injuries when a responsible person/party could not be contacted or for situations when the injured person cannot obtain reimbursement from the responsible person/party. Thus, most Chinese legislative documents related to social medical insurance do not provide reimbursement for medical expenses from injuries having a legally responsible person/party or those caused by illegal behaviors. We argue that all injury-induced medical expenses should be covered by legislative documents related to social medical insurance in China, no matter what the cause of the injury. Further research is needed to explore the acceptability and feasibility of such policy changes.