Ethnic disparities in traumatic brain injury care referral in a Hispanic-majority population

The effect of social determinants of health on patient outcomes in acute trauma: A systematic review

INTRODUCTION

Social determinants of health (SDoH) may mediate disparities, but their effect on outcomes after trauma is not well known. The purpose of this review is to improve existing gaps of knowledge for a broad range of SDoH and trauma-related outcomes.

METHODS

This was a systematic search to identify studies that evaluated the effect of race, insurance status, socioeconomic status (SES), health literacy, and community deprivation on inpatient mortality, morbidity, and post-discharge health care utilization in diverse trauma populations ≥16 years. Data were extracted on study design, patient and injury characteristics, outcomes, and covariates. Qualitative analysis was performed and reported results were stratified by exposure. An overall assessment of the strength of evidence for key clinically relevant comparisons was conducted.

RESULTS

60 studies were included. Overall, race was not meaningfully predictive of mortality or morbidity, with evidence reporting inconsistent or small magnitude of effects. However, African American/Black race was consistently associated with decreased odds of discharge to rehabilitation. Compared to insured patients, uninsured patients may have greater mortality risk and be less likely to discharge to rehabilitation. Studies evaluating health literacy or community deprivation reported conflicting results.

CONCLUSIONS

Disparities related to race are most profound for post-discharge health care utilization, while insurance status may be a strong negative predictor of both mortality and discharge disposition. More research is needed on health literacy and community deprivation to better understand mechanisms of disparity after trauma. Interventions targeted at improving continuity of inpatient and outpatient care may be beneficial.

Racial and Ethnic Disparities in Referral Rejection From Postacute Care Facilities Among People With Opioid Use Disorder in Massachusetts

OBJECTIVES

The aim of the study was to examine the association between Black, White, and Hispanic or Latino race and ethnicity and referral rejection from private postacute care facilities among hospitalized individuals with opioid use disorder (OUD).

METHODS

In this retrospective cohort study, we linked electronic postacute care referrals from Boston Medical Center in 2018 to electronic medical record data, which we used to ascertain OUD status and race and ethnicity. Using multivariable logistic regression, we examined the association between Black, White, and Hispanic or Latino race and ethnicity and referral rejection, adjusting for individual-level characteristics including medication for opioid use disorder treatment type and for facility-level factors using facility random effects.

RESULTS

We identified 159 hospitalizations from 141 individuals with OUD referred to private postacute medical care, corresponding to 1272 referrals to 244 facilities. Hospitalizations comprised 53 (33%) non-Hispanic Black, 28 (18%) Hispanic or Latino, and 78 (49%) non-Hispanic White individuals. In adjusted analyses, referrals for non-Hispanic Black individuals had significantly higher odds of rejection compared to referrals for non-Hispanic White individuals (adjusted odds ratio 1.83, 95% confidence interval [1.24, 2.69], P = 0.002). There were no significant differences between referrals for Hispanic or Latino individuals and non-Hispanic White individuals (adjusted odds ratio 1.11, 95% confidence interval [0.67, 1.84], P = 0.69).

CONCLUSIONS

Among people with OUD referred to private postacute care in Massachusetts, non-Hispanic Black individuals were more likely to be rejected compared to non-Hispanic White individuals, demonstrating racism in postacute care admissions. Efforts to address discrimination against people with OUD in postacute care admissions must also address racial equity.

Molecular Biomarkers Associated with Traumatic Brain Injury Outcome in Individuals of Black Racial Identity or African Ancestry: A Narrative Review

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and a major global health concern. In the United States, individuals of Black or African American racial identity experience disproportionately higher rates of TBI and suffer from worse postinjury outcomes. Contemporary research agendas have largely overlooked or excluded Black populations, resulting in the continued marginalization of Black patient populations in TBI studies, thereby limiting the generalizability of ongoing research to patients in the United States and around the world. This review aims to highlight what is currently known, and identify knowledge gaps, in research on molecular biomarkers associated with TBI in Black populations. A PubMed literature search was conducted to identify studies that investigate molecular biomarkers associated with TBI outcomes that include participants of Black racial identity and those of African ancestry. Studies identified for this review investigate biomarkers associated with TBI outcomes through a lens that specifically examines race, ethnicity, or ancestry. Most studies focused on blood- or cerebrospinal fluid-derived protein biomarkers. Studies identified statistical variation in S100ß, ubiquitin C-terminal hydrolase-L1, amyloid-ß, and tau across participant race, either at baseline or following TBI. Additionally, several studies identified genetic polymorphisms associated with TBI outcomes related to apolipoprotein E, ANKK1, and COMT polymorphism and TBI outcome and identified allele frequency variation across population ancestry. The role of race and ancestry on biomarkers associated with TBI outcome remains indeterminate and subsequent work is still required to understand the implications for patients with TBI.

Hispanic/Latino Ethnicity and Loss of Post-Surgery Independent Living: A Retrospective Cohort Study from a Bronx Hospital Network

BACKGROUND

Black race is associated with postoperative adverse discharge to a nursing facility, but the effects of Hispanic/Latino ethnicity are unclear. We explored the Hispanic paradox , described as improved health outcomes among Hispanic/Latino patients on postoperative adverse discharge to nursing facility.

METHODS

A total of 93,356 adults who underwent surgery and were admitted from home to Montefiore Medical Center in the Bronx, New York, between January 2016 and June 2021 were included. The association between self-identified Hispanic/Latino ethnicity and the primary outcome, postoperative adverse discharge to a nursing home or skilled nursing facility, was investigated. Interaction analysis was used to examine the impact of socioeconomic status, determined by estimated median household income and insurance status, on the primary association. Mixed-effects models were used to evaluate the proportion of variance attributed to the patient's residential area defined by zip code and self-identified ethnicity.

RESULTS

Approximately 45.9% (42,832) of patients identified as Hispanic/Latino ethnicity and 9.7% (9074) patients experienced postoperative adverse discharge. Hispanic/Latino ethnicity was associated with lower risk of adverse discharge (relative risk [RR adj ] 0.88; 95% confidence interval [CI], 00.82-0.94; P < .001), indicating a Hispanic Paradox . This effect was modified by the patient's socioeconomic status ( P -for-interaction <.001). Among patients with a high socioeconomic status, the Hispanic paradox was abolished (RR adj 1.10; 95% CI, 11.00-1.20; P = .035). Furthermore, within patients of low socioeconomic status, Hispanic/Latino ethnicity was associated with a higher likelihood of postoperative discharge home with health services compared to non-Hispanic/Latino patients (RR adj 1.06; 95% CI, 11.01-1.12; P = .017).

CONCLUSIONS

Hispanic/Latino ethnicity is a protective factor for postoperative adverse discharge, but this association is modified by socioeconomic status. Future studies should focus on postoperative discharge disposition and socioeconomic barriers in patients with Hispanic/Latino ethnicity.

Community resource facilitation use by ethnic minority groups with traumatic brain injury in the Midwestern United States

OBJECTIVE

This study surveyed the use of community-based resource facilitation (RF) services by ethnic minority survivors of traumatic brain injury (TBI) living in the Midwestern United States.

METHOD

Past records of RF use by survivors of TBI were reviewed. Demographics and patterns of RF use across 3 ethnic groups were documented. Reported barriers to community integration related to ethnic identity were identified using Chi-square test of independence.

RESULTS

Ethnic minority survivors were less likely to use RF services than white survivors. Caucasian women and men utilized RF services at similar rates, whereas more African American men and Latina women used RF services. Caucasians received information about RF from a greater variety of sources than ethnic minority survivors. Ethnic identity was significantly associated with greater reported needs for TBI awareness.

CONCLUSIONS

A pattern of differential RF use by survivors from ethnic minority groups was noted, suggesting potential socio-cultural influences on help-seeking behavior after TBI. These factors should be considered to develop more accessible and equitable strategies of RF service referral and support. Future investigations of cultural perspectives of TBI and injury-related services may improve understanding of the likelihood and necessity of community-based RF service use by diverse populations.

ENIGMA's simple seven: Recommendations to enhance the reproducibility of resting-state fMRI in traumatic brain injury

Resting state functional magnetic resonance imaging (rsfMRI) provides researchers and clinicians with a powerful tool to examine functional connectivity across large-scale brain networks, with ever-increasing applications to the study of neurological disorders, such as traumatic brain injury (TBI). While rsfMRI holds unparalleled promise in systems neurosciences, its acquisition and analytical methodology across research groups is variable, resulting in a literature that is challenging to integrate and interpret. The focus of this narrative review is to address the primary methodological issues including investigator decision points in the application of rsfMRI to study the consequences of TBI. As part of the ENIGMA Brain Injury working group, we have collaborated to identify a minimum set of recommendations that are designed to produce results that are reliable, harmonizable, and reproducible for the TBI imaging research community. Part one of this review provides the results of a literature search of current rsfMRI studies of TBI, highlighting key design considerations and data processing pipelines. Part two outlines seven data acquisition, processing, and analysis recommendations with the goal of maximizing study reliability and between-site comparability, while preserving investigator autonomy. Part three summarizes new directions and opportunities for future rsfMRI studies in TBI patients. The goal is to galvanize the TBI community to gain consensus for a set of rigorous and reproducible methods, and to increase analytical transparency and data sharing to address the reproducibility crisis in the field.

How Subjective and Objective Factors in Research and Practice May Perpetuate Health Disparities Among Patients With Traumatic Brain Injury

ABSTRACT

Research shows disparities exist in traumatic brain injury (TBI)-related outcomes and are associated with objective and subjective factors. Objective factors (e.g., age, sex, race/ethnicity, health insurance status, and socioeconomic status) are defined as variables that are frequently measured, not easily modifiable, and not easily influenced by individual perceptions, opinions, or experiences. Conversely, subjective factors (e.g., personal health literacy, cultural competence, patient/family-clinician communication, implicit bias, and trust) are defined as variables that may be less frequently measured, more easily modifiable, and more easily influenced by individual perceptions, opinions, or experiences. The purpose of this analysis and perspective is to provide recommendations for further examination of subjective factors within TBI research and practice, with the overarching goal of reducing TBI-related disparities. Establishing reliable and valid measures of subjective factors is recommended to allow for further examination of the influence of both objective factors and subjective factors in the TBI population. Providers and researchers must also engage in education and training to recognize their biases and how bias influences decision making. The influence of subjective factors in practice and research must also be considered to ensure that knowledge needed to advance health equity is generated and disparities in outcomes for patients with TBI are reduced.

Socioeconomic and clinical factors associated with prolonged hospital length of stay after traumatic brain injury

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.

Disparities Associated with Discharge Patterns in Firearm-Associated Ocular Trauma

Importance

Firearm injuries are associated with devastating visual outcomes. Several studies have demonstrated disparities in trauma care and discharge to rehabilitation and other advanced care facilities (ACFs) due to race and ethnicity and insurance status. The identification of possible disparities in disposition of patients admitted with firearms-associated ocular injuries (FAOIs) is a crucial step in moving toward health equity.

Objective

To describe disposition patterns following admission for FAOI trauma.

Design, Setting, and Participants

This retrospective analysis of National Trauma Data Bank (NTDB) from 2008 through 2014 used hospitalized trauma cases from over 900 US facilities detailed in the NTDB. Participants included patients admitted with ocular injuries. Statistical analysis was conducted between April 16, 2017, and December 15, 2021.

Exposure

Firearm injuries.

Main Outcomes and Measures

Patients admitted with FAOIs were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes. Demographic data, location, injury type and severity, and insurance status were documented. The primary outcome was the odds of discharge to ACFs.

Results

A total of 8715 of 235 254 firearms injuries involved the eye (3.7%). Of the 8715 included patients, 7469 were male (85.7%), 3050 were African American (35.0%), and 4065 White (46.6%), with a mean (SD) age of 33.8 (16.9) years. Common payments were government insurance (31.5%), self-paid insurance (29.4%), and commercial insurance plans (22.8%). Frequent dispositions were home (48.8%) and ACF (20.5%). Multivariate analysis demonstrated that the following factors were associated with the highest odds of discharge to an ACF: hospital stays 6 days or longer (odds ratio [OR], 3.05; 95% CI, 2.56-3.63; P < .001), age 65 years or older (OR, 2.94; 95% CI, 1.94-4.48; P < .001), associated traumatic brain injury (OR, 2.32; 95% CI, 1.94-2.78; P < .001), severe traumatic brain injury (OR, 2.10; 95% CI, 1.79-2.46; P < .001), and very severe Injury Severity Score (OR, 2.22; 95% CI, 1.88-2.62; P < .001). White race (OR, 2.00; 95% CI, 1.71-2.33; P < .001) was associated with higher odds than Medicare insurance (OR, 1.64; 95% CI, 1.16-2.31; P = .01).

Conclusions and Relevance

These findings suggest that older, more severely injured, Medicare-insured, or White patients have higher odds of ACF placement than younger, less severely injured, otherwise insured, and Black and Hispanic patients. This study is limited by its retrospective nature and the study team was unable to explore the basis for these disposition differences. Nevertheless, this work highlights that disparities may exist in disposition after FAOIs that may limit the rehabilitation potential of specific populations.

Exploring the Social Determinants of Health and Health Disparities in Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a global health concern, that can leave lasting physical, cognitive, and/or behavioral changes for many who sustain this type of injury. Because of the heterogeneity of this population, development of appropriate intervention tools can be difficult. Social determinants of health (SDoH) are factors that may impact TBI incidence, recovery, and outcome. The purpose of this study is to describe and analyze the existing literature regarding the prevailing SDoH and health disparities (HDs) associated with TBI in adults. A scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to explore three electronic databases-PubMed, Medline, and CINAHL. Searches identified peer-reviewed empirical literature addressing aspects of SDoH and HDs related to TBI. A total of 123 records were identified and reduced to 27 studies based on inclusion criteria. Results revealed race/ethnicity was the most commonly reported SDoH impacting TBI, followed by an individual's insurance status. Health disparities were noted to occur across the continuum of TBI, including TBI risk, acute hospitalization, rehabilitation, and recovery. The most frequently reported HD was that Whites are more likely to be discharged to inpatient rehabilitation compared to racial/ethnic minorities. Health disparities associated with TBI are most commonly associated with the race/ethnicity SDoH, though insurance status and socioeconomic status commonly influence health inequities as well. The additional need for evidence related to the impact of other, lesser researched, SDoH is discussed, as well as clinical implications that can be used to target intervention for at-risk groups using an individual's known SDoH.

Racial/Ethnic Differences in Traumatic Brain Injury: Pathophysiology, Outcomes, and Future Directions

Traumatic brain injury (TBI) is a major cause of death and disability in the United States, exacting a debilitating physical, social, and financial strain. Therefore, it is crucial to examine the impact of TBI on medically underserved communities in the U.S. The purpose of the current study was to review the literature on TBI for evidence of racial/ethnic differences in the U.S. Results of the review showed significant racial/ethnic disparities in TBI outcome and several notable differences in other TBI variables. American Indian/Alaska Natives have the highest rate and number of TBI-related deaths compared with all other racial/ethnic groups; Blacks/African Americans are significantly more likely to incur a TBI from violence when compared with Non-Hispanic Whites; and minorities are significantly more likely to have worse functional outcome compared with Non-Hispanic Whites, particularly among measures of community integration. We were unable to identify any studies that looked directly at underlying racial/ethnic biological variations associated with different TBI outcomes. In the absence of studies on racial/ethnic differences in TBI pathobiology, taking an indirect approach, we looked for studies examining racial/ethnic differences in oxidative stress and inflammation outside the scope of TBI as they are known to heavily influence TBI pathobiology. The literature indicates that Blacks/African Americans have greater inflammation and oxidative stress compared with Non-Hispanic Whites. We propose that future studies investigate the possibility of racial/ethnic differences in inflammation and oxidative stress within the context of TBI to determine whether there is any relationship or impact on TBI outcome.

Centering race/ethnicity: Differences in traumatic brain injury inpatient rehabilitation outcomes

BACKGROUND

Persons of color have a higher incidence of traumatic brain injury (TBI) and experience disparities in the quality and quantity of interventions received, discharge disposition, functional outcomes, and mortality rate post TBI.

OBJECTIVE

To examine racial/ethnic differences in rehabilitation outcomes for patients with TBI.

DESIGN

Multiyear (2005-2016) and retrospective cohort using secondary data analysis from inpatient rehabilitation facilities (IRFs) across the United States.

SETTING

eRehabData participating IRFs throughout the United States.

PATIENTS

Forty-one thousand eight hundred forty-seven adults with a diagnosis of TBI, admitted to U.S. eRehabData participating IRFs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Inpatient rehabilitation functional outcomes and discharge disposition.

RESULTS

Participants were 41,847 non-Hispanic Whites (NHWs), Hispanics, non-Hispanic Asians (NHAs), and non-Hispanic Blacks (NHBs) aged 18-107 years. NHWs were used as the reference group. NHBs had the longest length of stay (17.65 ± 14.96). At admission, NHB, Hispanic, and NHA races/ethnicities were significantly associated with 1-3 point lower motor, cognitive, and total Functional Independence Measure (FIM) scores. NHB race was significantly associated with less than 1-point lower cognitive, motor, and total efficiency FIM scores. At discharge, NHB race was significantly associated with 1-2 point lower motor, cognitive, and total FIM scores; Hispanics and NHA race were associated with less than 1-point lower cognitive FIM scores. Compared to NHWs, Hispanic ethnicity was associated with greater odds of a discharge to home (odds ratio = 1.16, 95% confidence interval = 1.06-1.27).

CONCLUSION

Contrary to established literature on functionality differences 1 year post TBI, the current study found racial/ethnic differences in functional outcomes during inpatient rehabilitation. These findings suggest a need for cultural competence/sensitivity in the care of racial/ethnic persons and centering potential contributing factors for racial/ethnic differences in TBI rehabilitation outcomes.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

BACKGROUND

Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI.

METHODS

We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics.

RESULTS

We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001).

CONCLUSIONS

Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

Adequacy of Healthcare by Insurance Type in Traumatic Brain Injury Patients

Traumatic brain injury (TBI) is a significant contributor to disability, especially among patients younger than 18 years old in the United States. While insurance is often needed to receive services, studies investigating whether TBI treatment adequacy is dependent on the insurance type are scant. Our objective was to determine whether private insurance in paediatric TBI patients is associated with a higher perceived adequacy of healthcare compared with non-private insurance. This was a cross-sectional study utilising secondary data collected from the National Survey of Children Health 2011/12. The main exposure of interest was the insurance status of children at the time of a TBI (private vs non-private). The study outcome was the perceived adequacy of healthcare, defined as having coverage needs that were usually or always met by insurance. Unadjusted and adjusted logistic regression analysis were used. After adjustments for the covariates, the odds of adequate healthcare among those with non-private insurance compared with those with private were not statistically significant (OR 1.49; 95% CI 0.87–2.55). This study implicates paediatric TBI patients do not believe they receive adequate healthcare independent of insurance status. Clinicians, policy makers, and researchers need to better evaluate and address this issue.

Identifying factors associated with acute hospital discharge dispositions in patients with moderate-to-severe traumatic brain injury

OBJECTIVE

Identify sociodemographic, injury, and hospital-level factors associated with acute hospital discharge dispositions following acute hospitalization for moderate-to-severe traumatic brain injury (TBI) in the United States.

METHODS

The 2011-2014 National Trauma Data Bank data was used, including 466 acute care hospitals and 114,736 patients ≥16 years old who survived moderate-to-severe TBI. Outcome was acute hospital discharge dispositions: home with/without care (HC), skilled nursing home/other care facility (SNF/ICF) and inpatient rehabilitation/long-term care facility (IRF). Independent variables were patients' sociodemographic, injury, and hospital-level factors. Multilevel modeling was used to assess associations and compare likelihood of discharges.

RESULTS

Of all patients, 74.5%, 14.6% ,and 10.9% were discharged to HC, SNF/ICF ,and IRF, respectively. Intraclass correlation coefficients indicated that hospitals explained 14.3% and 14.8% of variations in probabilities of institution dispositions. Sociodemographic factors including older age, females, Non-Hispanic Whites, recipients of commercial insurance, and Medicare/Medicaid were significantly associated with higher institution discharges. Hospital-related factors including bed size, teaching status, trauma accreditations, and hospital locations were significantly associated with discharge dispositions.

CONCLUSION

Identifying factors associated with discharge dispositions after acute hospitalization of TBI is pertinent to ensure quality of care and optimal patient outcomes. Further research into hospital-related variations in acute care discharge dispositions is recommended.

Employment probability trajectories in hispanics over the 10 years after traumatic brain injury: A model systems study

BACKGROUND

Research has found that Hispanics with traumatic brain injury (TBI) have reduced functional outcomes compared to non-Hispanic Whites, including lower probabilities of post-injury employment. However, previous studies were cross-sectional, combined racial/ethnic minority groups, and did not examine the factors that predict return to work of Hispanics longitudinally.

OBJECTIVE

To determine the demographic and injury-related predictors of employment probability trajectories during the first 10 years after TBI.

METHODS

1,346 Hispanics in the TBI Model Systems Database were included. Hierarchical linear modeling was used to examine baseline predictors of employment probability trajectories across this time period.

RESULTS

Employment probability demonstrated a quadratic movement over time, with an initial increase followed by a plateau or slight decrease. Hispanics with TBI had higher employment probability trajectories if they had been younger at the time of injury, spent less time in posttraumatic amnesia, had greater years of education, had been employed at the time of injury, had higher annual earnings at the time of injury, and had experienced a non-violent mechanism of injury.

CONCLUSION

Culturally adapted treatment programs with a focus on early intervention incorporating vocational rehabilitation and employment programs for Hispanics with TBI who present with these risk factors are needed.

Primary Language and Participation Outcomes in Hispanics With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine the relationship between primary language and participation outcomes in English- and Spanish-speaking persons with complicated mild to severe traumatic brain injury (TBI) at 1 year post-injury.

SETTING

Community following discharge from inpatient rehabilitation.

PARTICIPANTS

A total of 998 Hispanic participants with outcomes available at year 1 follow-up; 492 (49%) indicated English as their primary language and 506 (51%) indicated Spanish as their primary language.

DESIGN

Prospective, multicenter, cross-sectional, observational cohort study.

MAIN MEASURES

Community participation at 1 year post-injury was assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out and About, Productivity, and Social Relations.

RESULTS

Unadjusted group comparisons showed better participation outcomes for English versus Spanish speakers for all PART-O domains and for the Balanced Total score. After controlling for relevant covariates, English-speaking participants had significantly better PART-O Balanced Total scores and better scores on the Social Relations domain, although effect sizes were small.

CONCLUSIONS

Hispanic persons with TBI whose primary language is Spanish may require greater assistance integrating socially back into their communities after TBI. However, potential cultural differences in value placed on various social activities must be considered. Potential cultural bias inherent in existing measures of participation should be investigated in future studies.

Assessing lifetime exposure to traumatic brain injury among an international sample of Spanish speakers

BACKGROUND

With structured interviews being an established method for assessing one's exposure to traumatic brain injury across their lifetime, effective assessment tools are needed to serve the large population of Spanish speakers in the U.S. and abroad.

OBJECTIVE

To obtain preliminary evidence of validity for a Spanish version of a web-based, structured interview designed to assess lifetime exposure to TBI.

METHODS

A sample of 720 Spanish-speaking individuals between the ages of 18 through 65 from the continental U.S. (34.3%), South America (30.8%), the Caribbean (12.6%), Spain (12.4%), and Mexico and Central America (9.9%) completed an online survey containing the Ohio State University Traumatic Brain Injury Identification Method (Self-Administered-Brief; OSU TBI-ID SAB), Neurobehavioral Symptom Inventory, and PROMIS Cognitive Concerns Scale.

RESULTS

Indices of severity of worst TBI, time since most recent TBI, and multiple injuries demonstrated expected relationships with neurobehavioral symptoms such that greater symptom reporting was observed among those who had more severe injuries, more recent injuries, and multiple injuries over a period of time.

CONCLUSIONS

Findings provide preliminary evidence of validity for three of the indices derived from OSU TBI-ID SAB among Spanish-speaking individuals. Further study is needed to assess other aspects of this instrument to pave the way for further epidemiological studies involving lifetime exposure to TBI among Spanish-speaking individuals across the U.S., Spain, and Latin America.

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.

Outcomes in Critically Ill Patients With Traumatic Brain Injury: Ethnicity, Documentation, and Insurance Status

OBJECTIVES

Disparities in traumatic brain injury outcomes for ethnic minorities and the uninsured have previously been demonstrated; however, outcomes in undocumented immigrants have not been examined. We wanted to determine whether ethnicity, insurance, and documentation status served as risk factors for disparities in traumatic brain injury outcomes between undocumented immigrants and documented residents.

DESIGN

Retrospective study.

SETTING

Patients diagnosed with traumatic brain injury admitted to the surgical/trauma ICU at a level 1 trauma center serving a large immigrant population in New York City from 2009 to 2016.

PATIENTS

Four-hundred seventy-one traumatic brain injury patients requiring surgical/trauma ICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Undocumented immigrants constituted 29% of the population, were younger (39 vs 57 yr old, respectively; p < 0.0001), Hispanic (83%; p < 0.0001), and uninsured (87%; p < 0.0001). Falls resulted in the majority of traumatic brain injuries in the total population, however, undocumented immigrants were almost twice as likely to be assaulted (p = 0.0032). There was no difference in presence of midline shifts, Injury Severity Score, Glasgow Coma Score, hypotension, hypoxia, and pupillary reactions between undocumented immigrants and documented residents. Undocumented immigrants presented with significantly more effaced basilar cisterns (p = 0.0008). There was no difference in hospital care between undocumented immigrants and documented residents as determined by emergency department to surgical/trauma ICU transfer times (p = 0.967). Undocumented immigrants were more likely to be discharged home (53% vs 33%, respectively; p = 0.0009) and less likely to be sent to rehabilitation (25% vs 32%, respectively; p = 0.0009). After adjusting length of stay and mortality for covariates, undocumented immigrants had shorter length of stay (p < 0.05) and there was no difference in hospital mortality between undocumented immigrants and documented residents.

CONCLUSIONS

Undocumented immigrants with traumatic brain injuries were more likely to be younger, have shorter length of stay, and experience similar mortality rates to documented residents. Social economic status may play a role in events prior to hospitalization and likely does in disposition outcomes.

Race and ethnicity considerations in traumatic brain injury research: Incidence, reporting, and outcome

PRIMARY OBJECTIVE

This study has three goals: to determine whether there is a higher rate of traumatic brain injury (TBI) for people of color (POC), whether TBI studies report racial/ethnic demographics, and whether there is a discrepancy in discharge destinations between Whites and POC. We examined whether 1) a higher percentage of POC would sustain head injuries than expected, 2) the majority of TBI studies examined (>50%) would not include racial/ethnic demographics, and 3) Whites would be discharged to further treatment over POC.

RESEARCH DESIGN

Retrospective study and literature review.

METHODS AND PROCEDURES

Data from the Pennsylvania Trauma System Foundation was used to determine the number of POC with TBI using X ² analysis, as well as where patients with TBI were being discharged using a configural frequency analysis. PubMed was used for the literature search to examine the frequency of reporting race/ethnicity in TBI literature.

MAIN OUTCOMES AND RESULTS

Results demonstrated that Blacks sustain more TBIs than would be expected (p < .05), the majority of scientific studies (78%) do not report racial/ethnic demographic information, and Whites are discharged to further care more often than POC.

CONCLUSIONS

These findings highlight differences in incidence and treatment of TBI between White individuals and POC, raising important considerations for providers and researchers.

Is trauma center designation associated with disparities in discharge to rehabilitation centers among elderly patients with Traumatic Brain Injury?

BACKGROUND

We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI).

METHODS

The National Trauma Data Bank (2014-2015) was used to identify elderly (age ≥ 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared.

RESULTS

3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, p = 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, p = 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, p = 0.01).

CONCLUSION

Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.

Reducing neurodisparity: Recommendations of the 2017 AAN Diversity Leadership Program

Many advances in prevention, diagnosis, and treatment of neurologic disease have emerged in the last few decades, resulting in reduced mortality and decreased disability. However, these advances have not benefitted all populations equally. A growing body of evidence indicates that barriers to care fall along racial and ethnic lines, with persons from minority groups frequently having lower rates of evaluation, diagnosis, and intervention, and consequently experiencing worse neurologic outcomes than their white counterparts. The American Academy of Neurology (AAN) challenged its 2017 Diversity Leadership Program cohort to determine what the AAN can do to improve quality of care for racially and ethnically diverse patients with neurologic disorders. Developing a fuller understanding of the effect of disparities in neurologic care (neurodisparity) on patients is an important prerequisite for creating meaningful change. Clear insight into how bias and trust affect the doctor-patient relationship is also crucial to grasp the complexity of this issue. We propose that the AAN take a vital step toward achieving equity in neurologic care by enhancing health literacy, patient education, and shared decision-making with a focus on internet and social media. Moreover, by further strengthening its focus on health disparities research and training, the AAN can continue to inform the field and aid in the development of current and future leaders who will address neurodisparity. Ultimately, the goal of tackling neurodisparity is perfectly aligned with the mission of the AAN: to promote the highest-quality patient-centered neurologic care and enhance member career satisfaction.