Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations

Physicians' Perceptions of Barriers and Facilitators to the Improvement of Healthcare Equity for Children Hospitalized With Traumatic Brain Injury: Preliminary Findings From a Pilot Multicenter Pediatric Trauma Study From the United States

Background and objective Disparities in outcomes for pediatric patients with traumatic brain injuries (TBI) in rural populations and for racial and ethnic minority groups have been documented. In light of this, we examined physician champions' perceptions of healthcare equity for hospitalized children with TBI. Methods We surveyed 10 physician TBI champions at 10 US pediatric trauma centers (PTCs) regarding organizational characteristics, barriers, and facilitators (domains and specific) in terms of improving healthcare equity, and priorities to redress inequities. Results Level I center TBI champions reported more pediatric beds and higher staffing-to-patient ratios while Level II TBI champions reported more pediatric TBI transfers. Across PTCs, the leading specific barriers were lack of access to post-discharge services, lack of staff training, and inadequate staffing. Level I PTCs identified a lack of knowledge about resources while Level II centers identified low hospital staffing numbers and lack of staff training as specific barriers. Across all PTCs, the leading specific facilitators were providers being up to date on skills, treatments, continuing education, team structure and cohesion, and quality improvement and protocol implementation. Across all PTCs, priorities to address barrier domains were staffing, cost and supply constraints, and organizational and structural domains, whereas priorities for facilitator domains were staffing, organizational and structural, and culture of change with variation in priority ranking to address barriers and facilitators by PTC level type. Physician champions identified common and unique barriers and facilitators to providing equitable healthcare for children hospitalized with TBI by PTC level type. Conclusions Respondents across all PTCs reported a set of common leading specific barriers and facilitators. Level I and Level II PTCs reported common specific barriers but more variable specific facilitators. Across all PTCs, the most frequently reported barrier domains were not always of the highest priority to redress.

Barriers and Facilitators of Home Programmes in Children With Cerebral Palsy: A Systematic Review and a Metasynthesis

INTRODUCTION

One of the treatments with the greater scientific support for children with cerebral palsy (CP) are home programmes (HP). However, its implementation may be complex in some cases. A systematic review was conducted to explore the existing literature on the following question: What are the barriers and facilitators to implementing HP for children with CP?

MATERIAL AND METHODS

The articles were extracted from the Web of Science (WoS), Scopus, ERIC, PubMed and CINAHL databases.

INCLUSION CRITERIA

articles based on therapies conducted at home, for children with CP aged 0-8 years and their families, published in English and Spanish.

EXCLUSION CRITERIA

reviews, studies of cases and controls and one-case studies. The risk of bias was assessed through Cochrane tools Risk of Bias (RoB) I, RoB 2 and RoB E.

RESULTS

Twenty-one articles were selected from a total of 1.336, with 523 families and professionals. A qualitative research was carried out through content analysis using inductive coding and subsequent analytical categorization within an interpretative paradigm. Six themes were obtained: participation, personal cost and social support, family impact, training, professional role and efficacy. The quantitative results were analysed descriptively. They address HP research in a superficial manner.

CONCLUSIONS

Barriers: lack of time or availability to attend to the children one by one, poor economic and social support networks and sensitive emotional situation. Facilitators: training, adapted treatment objectives, activities within the daily routine and fluid family-professional communication.

LIMITATION

Only one article could be found that analysed family variables, considering the possible confounding variables. There is no funding source for this review. Registered in PROSPERO with code number: CRD42023477735.

Exploring the care coordination experiences of professionals and caregivers of youth with acquired brain injuries in rural areas

PURPOSE

Acquired brain injuries (ABIs) can have devastating effects on children and their families. Families living in rural communities experience unique barriers to receiving and coordinating care for complex medical needs, but little research has examined those barriers for rural youth with ABIs.

MATERIALS AND METHODS

This qualitative study explored the experiences of rural adults caring for children with ABIs through interviews with six caregivers, three school staff members, and three medical professionals who had treated at least one child with an ABI.

RESULTS

Themes in their accounts include difficulty navigating complex situations, support from small communities, isolation and loneliness, the need for more professional education about ABI, and feelings of hope. Barriers to quality care coordination include navigating complex situations, access to transportation, and a lack of communication and education from healthcare agencies. Facilitators of rural care coordination include support from small communities and interagency communication.

CONCLUSIONS

The results support the need for more comprehensive coordination among rural agencies involved in ABI care. Suggestions for care improvement include providing flexibility due to transportation barriers, capitalizing on the benefits of a small and caring community, and providing healthcare and education professionals with more education about ABI interventions.

Mortality trends of traumatic brain injuries in the adult population of the United States: a CDC WONDER analysis from 1999 to 2020

BACKGROUND

Traumatic Brain Injury (TBI) is a critical public health issue in the United States, contributing significantly to morbidity, mortality, and healthcare costs. Accounting for a substantial proportion of injury-related deaths and disabilities, TBI impacts a wide demographic, with particularly high incidence rates among young and elderly populations. Despite earlier declines, recent years have seen an uptick in TBI-related fatalities. This study aimed to evaluate the patterns and geographical disparities in mortality related to TBI among the adult population in the United States.

METHODS

We examined the death certificates sourced from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database to identify adults in whom TBI was documented as an underlying or contributing cause of death between 1999 and 2020. Age-adjusted mortality rates (AAMRs) per 100,000 individuals and annual percent change (APC) were computed and stratified based on year, gender, race/ethnicity, and geographic region.

RESULTS

Between 1999 and 2020, 1,026,185 TBI-related deaths occurred among adults aged ≥ 25 years. The AAMR remained stable from 22.2 in 1999 to 22.3 in 2007, followed by an insignificant decline to 21.5 in 2010, and a steeper significant subsequent increase to 24.6 in 2020. Men had consistently higher AAMR than women from 1999 (men: 35.6; women: 11.1) to 2020 (men: 38.8; women: 11.9). The 85 + years age group had the highest AAMR 118.5 trailed by 75-84-year age group at 53.2. American Indian or Alaska Native adults had the highest AAMR (31.9) followed by White (24.4). South had the highest AAMR (25.3), followed by West (22.7). Non-metropolitan areas consistently had higher mortality rates compared to metropolitan areas.

CONCLUSIONS

Following a brief period of stability in TBI-related mortality from 1999 to 2010, there has been a subsequent increase of 1.3% per year in mortality till 2020. Notable geographic and demographic disparities persist, underscoring the need for further research and precise health policy interventions to better understand and address these differences.

Comparison of Machine Learning Models in Predicting Mental Health Sequelae Following Concussion in Youth

Youth who experience concussions may be at greater risk for subsequent mental health challenges, making early detection crucial for timely intervention. This study utilized Bidirectional Long Short-Term Memory (BiLSTM) networks to predict mental health outcomes following concussion in youth and compared its performance to traditional models. We also examined whether incorporating social determinants of health (SDoH) improved predictive power, given the disproportionate impact of concussions and mental health issues on disadvantaged populations. We evaluated the models using accuracy, area under the curve (AUC) of the receiver operating characteristic (ROC), and other performance metrics. Our BiLSTM model with SDoH data achieved the highest accuracy (0.883) and AUC-ROC score (0.892). Unlike traditional models, our approach provided real-time predictions at each visit within 12 months of the index concussion, aiding clinicians in making timely, visit-specific referrals for further treatment and interventions.

Modeling healthcare demands and long-term costs following pediatric traumatic brain injury

Introduction

Traumatic brain injury (TBI) is a leading cause of death and disability in children, but data on the longitudinal healthcare and financial needs of pediatric patients is limited in scope and duration. We sought to describe and predict these metrics following acute inpatient treatment for TBI.

Methods

Children surviving their initial inpatient treatment for TBI were identified from Optum's deidentified Clinformatics® Data Mart Database (2007-2018). Treatment cost, healthcare utilization, and future inpatient readmission were stratified by follow-up intervals, type of claim, and injury severity. Both TBI-related and non-TBI related future cost and healthcare utilization were explored using linear mixed models. Acute inpatient healthcare utilization metrics were analyzed and used to predict future treatment cost and healthcare demands using linear regression models.

Results

Among 7,400 patients, the majority suffered a mild TBI (50.2%). For patients with at least one-year follow-up (67.7%), patients accrued an average of 28.7 claims and $27,199 in costs, with 693 (13.8%) readmitted for TBI or non-TBI related causes. Severe TBI patients had a greater likelihood of readmission. Initial hospitalization length of stay and discharge disposition other than home were significant positive predictors of healthcare and financial utilization at one-and five-years follow-up. Linear mixed models demonstrated that pediatric TBI patients would accrue 21.1 claims and $25,203 in cost in the first year, and 9.4 claims and $4,147 in costs every additional year, with no significant differences based on initial injury severity.

Discussion

Pediatric TBI patients require long-term healthcare and financial resources regardless of injury severity. Our cumulative findings provide essential information to clinicians, caretakers, researchers, advocates, and policymakers to better shape standards, expectations, and management of care following TBI.

Predicting and improving outcome in severe pediatric traumatic brain injury

INTRODUCTION

Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments.

AREAS COVERED

The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions.

EXPERT OPINION

There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.

Advances in Neurorehabilitation: Strategies and Outcomes for Traumatic Brain Injury Recovery

Traumatic brain injury (TBI) consists of an external physical force that causes brain function impairment or pathology and globally affects 50 million people each year, with a cost of 400 billion US dollars. Clinical presentation of TBI can occur in many forms, and patients usually require prolonged hospital care and lifelong rehabilitation, which leads to an impact on the quality of life. For this narrative review, no particular method was used to extract data. With the aid of health descriptors and Medical Subject Heading (MeSH) terms, a search was thoroughly conducted in databases such as PubMed and Google Scholar. After the application of exclusion and inclusion criteria, a total of 146 articles were effectively used for this review. Results indicate that rehabilitation after TBI happens through neuroplasticity, which combines neural regeneration and functional reorganization. The role of technology, including artificial intelligence, virtual reality, robotics, computer interface, and neuromodulation, is to impact rehabilitation and life quality improvement significantly. Pharmacological intervention, however, did not result in any benefit when compared to standard care and still needs further research. It is possible to conclude that, given the high and diverse degree of disability associated with TBI, rehabilitation interventions should be precocious and tailored according to the individual's needs in order to achieve the best possible results. An interdisciplinary patient-centered care health team and well-oriented family members should be involved in every stage. Lastly, strategies must be adequate, well-planned, and communicated to patients and caregivers to attain higher functional outcomes.

Do Racial and Ethnic Disparities Exist in Intensity of Intracranial Pressure-Directed Therapies and Outcomes Following Pediatric Severe Traumatic Brain Injury?

INTRODUCTION

Studies suggest disparities in outcomes in minoritized children after severe traumatic brain injury. We aimed to evaluate for disparities in intracranial pressure-directed therapies and outcomes after pediatric severe traumatic brain injury.

METHODS

We conducted a secondary analysis of the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial, which enrolled pediatric severe traumatic brain injury patients (Glasgow Coma Scale score  ≤8) with an intracranial pressure monitor from 2014 to 2018. Patients admitted outside of the United States were excluded. Patients were categorized by race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, and "Other"). We evaluated outcomes by assessing mortality and 3-month Glasgow Outcome Score-Extended for Pediatrics. Our analysis involved parametric and nonparametric testing.

MAIN RESULTS

A total of 671 children were analyzed. Significant associations included older age in non-Hispanic White patients (P < .001), more surgical evacuations in "Other" (P < .001), and differences in discharge location (P = .040). The "other" cohort received hyperventilation less frequently (P = .046), although clinical status during Paco2 measurement was not known. There were no other significant differences in intracranial pressure-directed therapies. Hispanic ethnicity was associated with lower mortality (P = .004) but did not differ in unfavorable outcome (P = .810). Glasgow Outcome Score-Extended for Pediatrics was less likely to be collected for non-Hispanic Black patients (69%; P = .011).

CONCLUSIONS

Our analysis suggests a general lack of disparities in intracranial pressure-directed therapies and outcomes in children after severe traumatic brain injury. Lower mortality in Hispanic patients without a concurrent decrease in unfavorable outcomes, and lower availability of Glasgow Outcome Score-Extended for Pediatrics score for non-Hispanic Black patients merit further investigation.

Setting an agenda for a national pediatric trauma system: Operationalization of the Pediatric Trauma State Assessment Score

ABSTRACT

Pediatric trauma system development is essential to public health infrastructure and pediatric health systems. Currently, trauma systems are managed at the state level, with significant variation in consideration of pediatric needs. A recently developed Pediatric Trauma System Assessment Score (PTSAS) demonstrated that states with lower PTSAS have increased pediatric mortality from trauma. Critical gaps are identified within six PTSAS domains: Legislation and Funding, Access to Care, Injury Prevention and Recognition, Disaster, Quality Improvement and Trauma Registry, and Pediatric Readiness. For each gap, a recommendation is provided regarding the necessary steps to address these challenges. Existing national organizations, including governmental, professional, and advocacy, highlight the potential partnerships that could be fostered to support efforts to address existing gaps. The organizations created under the US administration are described to highlight the ongoing efforts to support the development of pediatric emergency health systems.It is no longer sufficient to describe the disparities in pediatric trauma outcomes without taking action to ensure that the health system is equipped to manage injured children. By capitalizing on organizations that intersect with trauma and emergency systems to address known gaps, we can reduce the impact of injury on all children across the United States.

Current state of neuroprotective therapy using antibiotics in human traumatic brain injury and animal models

TBI is a leading cause of death and disability in young people and older adults worldwide. There is no gold standard treatment for TBI besides surgical interventions and symptomatic relief. Post-injury infections, such as lower respiratory tract and surgical site infections or meningitis are frequent complications following TBI. Whether the use of preventive and/or symptomatic antibiotic therapy improves patient mortality and outcome is an ongoing matter of debate. In contrast, results from animal models of TBI suggest translational perspectives and support the hypothesis that antibiotics, independent of their anti-microbial activity, alleviate secondary injury and improve neurological outcomes. These beneficial effects were largely attributed to the inhibition of neuroinflammation and neuronal cell death. In this review, we briefly outline current treatment options, including antibiotic therapy, for patients with TBI. We then summarize the therapeutic effects of the most commonly tested antibiotics in TBI animal models, highlight studies identifying molecular targets of antibiotics, and discuss similarities and differences in their mechanistic modes of action.

Establishing an imaging protocol for pediatric trauma in a rural hospital

Background

Rural hospitals cover 20% of the United States (US) population with only 10% of physician coverage. A mismatch exists in pediatric trauma resources as there is overwhelming trauma support concentrated in urban trauma centers. Well-established guidelines for evaluating pediatric trauma patients in resource-limited environments are currently not available. Herein we identify the imaging practices at a level III rural trauma center to establish a protocol for handling pediatric traumas.

Materials and Methods

The National Trauma Data Bank was used to identify 155 pediatric trauma patients (age <17 years) between 2017 and 2021. A single-center retrospective chart review was performed to identify patient demographics, mechanism of injury, imaging performed and pertinent imaging findings, and management of the patient i.e., whether they were discharged, admitted, or transferred.

Results

Blunt mechanisms were responsible for most traumas (90%). There were 64 patients (41.3%) who received imaging. Falls (49.3%) were the most common injury. Most of the patients were discharged home (73.4%) and 23.9% were transferred to a tertiary center. The mean time for transfer to a tertiary center was ∼176 min. The most frequently performed type of surgical intervention was orthopedic (59.3%).

Conclusion

An established pediatric trauma imaging protocol is warranted to adopt a higher level of pediatric trauma care for treatment and/or stabilization purposes. Using a tertiary care model and established pediatric trauma guidelines, we propose a model for use in resource-limited rural settings and aim to reduce unnecessary imaging of pediatric trauma patients and overall radiation exposure.

Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care

BACKGROUND

Disparities in trauma outcomes and care are well established for adults, but the extent to which similar disparities are observed in pediatric trauma patients requires further investigation. The objective of this study was to evaluate the unique contributions of social determinants (race, gender, insurance status, community distress, rurality/urbanicity) on trauma outcomes after controlling for specific injury-related risk factors.

STUDY DESIGN

All pediatric (age < 18) trauma patients admitted to a single level 1 trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed (n = 14,398). Primary outcomes were receipt of opioids in the emergency department, post-discharge rehabilitation referrals, and mortality. Multivariate logistic regressions evaluated demographic, socioeconomic, and injury characteristics. Multilevel logistic regressions evaluated area-level indicators, which were derived from abstracted home addresses.

RESULTS

Analyses adjusting for demographic and injury characteristics revealed that Black children (n = 6255) had significantly lower odds (OR = 0.87) of being prescribed opioid medications in the emergency department compared to White children (n = 5883). Children living in more distressed and rural communities had greater odds of receiving opioid medications. Girls had significantly lower odds (OR = 0.61) of being referred for rehabilitation services than boys. Post hoc analyses revealed that Black girls had the lowest odds of receiving rehabilitation referrals compared to Black boys and White children.

CONCLUSION

Results highlight the need to examine both main and interactive effects of social determinants on trauma care and outcomes. Findings reinforce and expand into the pediatric population the growing notion that traumatic injury care is not immune to disparities.

Update on Pediatric Mild Traumatic Brain Injury in Rural and Underserved Regions: A Global Perspective

BACKGROUND

Mild traumatic brain injury (MTBI) causes morbidity and disability worldwide. Pediatric patients are uniquely vulnerable due to developmental and psychosocial factors. Reduced healthcare access in rural/underserved communities impair management and outcome. A knowledge update relevant to current gaps in care is critically needed to develop targeted solutions.

METHODS

The National Library of Medicine PubMed database was queried using comprehensive search terms (("mild traumatic brain injury" or "concussion") and ("rural" or "low-income" or "underserved") and ("pediatric" or "child/children")) in the title, abstract, and Medical Subject Headings through December 2022. Fifteen articles on rural/underserved pediatric MTBI/concussion not covered in prior reviews were examined and organized into four topical categories: epidemiology, care practices, socioeconomic factors, and telehealth.

RESULTS

Incidences are higher for Individuals in rural regions, minorities, and those aged 0-4 years compared to their counterparts, and are increasing over time. Rural healthcare utilization rates generally exceed urban rates, and favor emergency departments (vs. primary care) for initial injury assessment. Management guidelines require customization to resource-constrained settings for implementation and adoption. Decreased community recognition of the seriousness of injury is a consensus challenge to care provision by clinicians. Low parental education and income were correlated with decreased MTBI knowledge and worse outcome. Telehealth protocols for triage/consultation and rehabilitation were feasible in improving care delivery to rural and remote settings.

CONCLUSIONS

Pediatric MTBI/concussion patients in rural/underserved regions experience increased risks of injury, geographic and financial healthcare barriers, and poorer outcomes. Globally, under-reporting of injury has hindered epidemiological understanding. Ongoing MTBI education should be implemented for rural caregivers, schools, and low-income populations to improve community awareness. Telehealth can improve care delivery across acuity settings, and warrants judicious inclusion in triage and treatment protocols.

The role of social determinants of health in the receipt of school services after\\ traumatic brain injury: A focus review on underserved pediatric populations

BACKGROUND

Return to school is key for community re-integration after a traumatic brain injury (TBI). School support facilitates and ensure a successful transition back to school. However, access to school services is not uniform among U.S. children.

OBJECTIVE

To describe school services for children with TBI from minoritized backgrounds and highlight population-specific risk factors and facilitators for accessing services.

METHODS

Narrative review of the literature including studies on return to school after a mild-complicated, moderate, or severe TBI, among children enrolled in the U.S. school system. We describe receipt of services, enabling and risk factors, and outcomes, for minority children.

RESULTS

There is a gap in knowledge regarding return to school among minoritized children with TBIs. Studies have few participants from racial and ethnic minority backgrounds, or low income or rural communities. Transgender and non-binary youth are not represented in present research efforts. Studies highlight larger barriers to receipt of school services among minority children and additional barriers associated with their minority status.

CONCLUSION

Diversity in the U.S pediatric population is increasing. Minoritized populations are at increased risk for TBI and poor outcomes. Research focused on the needs of these populations is required to optimize school return after TBI hospitalization and overall post-discharge care.

Area-Level Socioeconomic Inequalities in Intracranial Injury-Related Hospitalization in Korea: A Retrospective Analysis of Data From Korea National Hospital Discharge Survey 2008-2015

BACKGROUND

Although inequality in traumatic brain injury (TBI) by individual socioeconomic status (SES) exists, interventions to modify individual SES are difficult. However, as interventions for area-based SES can affect the individual SES, monitoring or public health intervention can be planned. We analyzed the effect of area-based SES on hospitalization for TBI and revealed yearly inequality trends to provide a basis for health intervention.

METHODS

We included patients who were hospitalized due to intracranial injuries (ICIs) between 2008 and 2015 as a measure of severe TBI with data provided by the Korea National Hospital Discharge Survey. Area-based SES was synthesized using the 2010 census data. We assessed inequalities in ICI-related hospitalization rates using the relative index of inequality and the slope index of inequality for the periods 2008-2009, 2010-2011, 2012-2013, and 2014-2015. We analyzed the trends of these indices for the observation period by age and sex.

RESULTS

The overall relative indices of inequality for each 2-year period were 1.82 (95% confidence interval, 1.5-2.3), 1.97 (1.6-2.5), 2.01 (1.6-2.5), and 2.01 (1.6-2.5), respectively. The overall slope indices of inequality in each period were 38.74 (23.5-54.0), 36.75 (21.7-51.8), 35.65 (20.7-50.6), and 43.11 (27.6-58.6), respectively. The relative indices of inequality showed a linear trend for men (P = 0.006), which was most evident in the ≥ 65-year age group.

CONCLUSION

Inequality in hospitalization for ICIs by area-based SES tended to increase during the observation period. Practical preventive interventions and input in healthcare resources for populations with low area-based SES are likely needed.

Variability Across Caregiver and Performance-Based Measures of Executive Functioning in an Acute Pediatric Neurocritical Care Population

Youth admitted to the pediatric intensive care unit (PICU) for traumatic brain injury (TBI) commonly struggle with long-term residual effects in the domains of physical, cognitive, emotional, and psychosocial/family functioning. In the cognitive domain, executive functioning (EF) deficits are often observed. The Behavior Rating Inventory of Executive Functioning, Second Edition (BRIEF-2) is a parent/caregiver-completed measure that is regularly utilized to assess caregivers' perspectives of daily EF abilities. Using parent/caregiver-completed measures like the BRIEF-2 in isolation as outcome measures for capturing symptom presence and severity might be problematic given that caregiver ratings are vulnerable to influence from external factors. As such, this study aimed to investigate the association between the BRIEF-2 and performance-based measures of EF in youth during the acute recovery period post-PICU admission for TBI. A secondary aim was to explore associations among potential confounding factors, including family-level distress, injury severity, and the impact of pre-existing neurodevelopmental conditions. Participants included 65 youths, 8-19 years of age, admitted to the PICU for TBI, who survived hospital discharge and were referred for follow-up care. Non-significant correlations were found between BRIEF-2 outcomes and performance-based measures of EF. Measures of injury severity were strongly correlated with scores from performance-based EF measures, but not BRIEF-2. Parent/caregiver-reported measures of their own health-related quality of life were related to caregiver responses on the BRIEF-2. Results demonstrate the differences captured by performance-based versus caregiver-report measures of EF, and also highlight the importance of considering other morbidities related to PICU admission.

Pediatric Traumatic Brain Injury in a Geographically Dispersed Population: A Relationship Between Distance to Definitive Neurosurgical Treatment and Outcome

BACKGROUND

There are limited data on the association between transport distance and outcomes in pediatric patients with severe traumatic brain injuries (sTBIs), despite children having to travel further to pediatric trauma centers (PTCs).

OBJECTIVE

To assess whether distance from a PTC is associated with outcomes in children who undergo cranial surgery after sTBI.

METHODS

Children with sTBI who underwent craniectomy/craniotomy at our PTC between 2010 and 2019 were identified retrospectively. Of these 92 patients, 83 sustained blunt injury and underwent surgery within 24 hours. The distance from injury location to PTC was based on injury zip code and calculated as Euclidean distance. Variables associated with transport, including distance, time, and rural-urban disparity, were analyzed for correlation with poor outcome.

RESULTS

Of the 83 patients identified, 81 had injury location information. Forty patients were injured within 30 miles and 41 were injured ≥30 miles from the PTC. Injury severity and pediatric trauma scores were not significantly different between groups. Sixty-eight children (82%) had a satisfactory outcome and 10 children (12%) died. There was a nonsignificant association between distance traveled and poor outcome, even when the cohort was stratified into those with subdural hematomas and those with nonabusive injuries.

CONCLUSIONS

Regardless of the distance from the PTC at which their injury occurred, most children in this cohort made a moderate to good recovery. Children injured at greater distances from the PTC did not have worse outcomes; however, studies with larger cohorts are needed to more definitively assess prehospital pediatric transport systems in this population.

Do social determinants of health impact access to neurosurgical care in the United States? A workforce perspective

OBJECTIVE

This study attempts to use neurosurgical workforce distribution to uncover the social determinants of health that are associated with disparate access to neurosurgical care.

METHODS

Data were compiled from public sources and aggregated at the county level. Socioeconomic data were provided by the Brookings Institute. Racial and ethnicity data were gathered from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research. Physician density was retrieved from the Health Resources and Services Administration Area Health Resources Files. Catchment areas were constructed based on the 628 counties with neurosurgical coverage, with counties lacking neurosurgical coverage being integrated with the nearest covered county based on distances from the National Bureau of Economic Research's County Distance Database. Catchment areas form a mutually exclusive and collectively exhaustive breakdown of the entire US population and licensed neurosurgeons. Socioeconomic factors, race, and ethnicity were chosen as independent variables for analysis. Characteristics for each catchment area were calculated as the population-weighted average across all contained counties. Linear regression analysis modeled two outcomes of interest: neurosurgeon density per capita and average distance to neurosurgical care. Coefficient estimates (CEs) and 95% confidence intervals were calculated and scaled by 1 SD to allow for comparison between variables.

RESULTS

Catchment areas with higher poverty (CE = 0.64, 95% CI 0.34-0.93) and higher prime age employment (CE = 0.58, 95% CI 0.40-0.76) were significantly associated with greater neurosurgeon density. Among categories of race and ethnicity, catchment areas with higher proportions of Black residents (CE = 0.21, 95% CI 0.06-0.35) were associated with greater neurosurgeon density. Meanwhile, catchment areas with higher proportions of Hispanic residents displayed lower neurosurgeon density (CE = -0.17, 95% CI -0.30 to -0.03). Residents of catchment areas with higher housing vacancy rates (CE = 2.37, 95% CI 1.31-3.43), higher proportions of Native American residents (CE = 4.97, 95% CI 3.99-5.95), and higher proportions of Hispanic residents (CE = 2.31, 95% CI 1.26-3.37) must travel farther, on average, to receive neurosurgical care, whereas people living in areas with a lower income (CE = -2.28, 95% CI -4.48 to -0.09) or higher proportion of Black residents (CE = -3.81, 95% CI -4.93 to -2.68) travel a shorter distance.

CONCLUSIONS

Multiple factors demonstrate a significant correlation with neurosurgical workforce distribution in the US, most notably with Hispanic and Native American populations being associated with greater distances to care. Additionally, higher proportions of Hispanic residents correlated with fewer neurosurgeons per capita. These findings highlight the interwoven associations among socioeconomics, race, ethnicity, and access to neurosurgical care nationwide.

Outcomes in Patients With Mild Traumatic Brain Injury Without Acute Intracranial Traumatic Injury

IMPORTANCE

Traumatic brain injury (TBI) affects millions of people in the US each year. Most patients with TBI seen in emergency departments (EDs) have a Glasgow Coma Scale (GCS) score of 15 and a head computed tomography (CT) scan showing no acute intracranial traumatic injury (negative head CT scan), yet the short-term and long-term functional outcomes of this subset of patients remain unclear.

OBJECTIVE

To describe the 2-week and 6-month recovery outcomes in a cohort of patients with mild TBI with a GCS score of 15 and a negative head CT scan.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed participants who were enrolled from January 1, 2014, to December 31, 2018, in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective, observational cohort study of patients with TBI that was conducted in EDs of 18 level I trauma centers in urban areas. Of the total 2697 participants in the TRACK-TBI study, 991 had a GCS score of 15 and negative head CT scan and were eligible for inclusion in this analysis. Data were analyzed from September 1, 2021, to May 30, 2022.

MAIN OUTCOMES AND MEASURES

The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E) score, which was stratified according to functional recovery (GOS-E score, 8) vs incomplete recovery (GOS-E score, <8), at 2 weeks and 6 months after the injury. The secondary outcome was severity of mild TBI-related symptoms assessed by the Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score.

RESULTS

A total of 991 participants (mean [SD] age, 38.5 [15.8] years; 631 male individuals [64%]) were included. Of these participants, 751 (76%) were followed up at 2 weeks after the injury: 204 (27%) had a GOS-E score of 8 (functional recovery), and 547 (73%) had a GOS-E scores less than 8 (incomplete recovery). Of 659 participants (66%) followed up at 6 months after the injury, 287 (44%) had functional recovery and 372 (56%) had incomplete recovery. Most participants with incomplete recovery reported that they had not returned to baseline or preinjury life (88% [479 of 546]; 95% CI, 85%-90%). Mean RPQ score was 16 (95% CI, 14-18; P < .001) points lower at 2 weeks (7 vs 23) and 18 (95% CI, 16-20; P < .001) points lower at 6 months (4 vs 22) in participants with a GOS-E score of 8 compared with those with a GOS-E score less than 8.

CONCLUSIONS AND RELEVANCE

This study found that most participants with a GCS score of 15 and negative head CT scan reported incomplete recovery at 2 weeks and 6 months after their injury. The findings suggest that emergency department clinicians should recommend 2-week follow-up visits for these patients to identify those with incomplete recovery and to facilitate their rehabilitation.

Challenges and opportunities in diagnosing and managing mild traumatic brain injury in rural settings

INTRODUCTION

There is some evidence to suggest that Americans living in rural areas are at increased risk for sustaining a traumatic brain injury (TBI) compared to those living in urban areas. In addition, once a TBI has been sustained, rural residents have worse outcomes, including a higher risk of death. Individuals living in rural areas tend to live farther from hospitals and have less access to TBI specialists. Aside from these factors, little is known what challenges healthcare providers practicing in rural areas face in diagnosing and managing TBI in their patients and what can be done to overcome these challenges.

METHODS

Seven focus groups and one individual interview were conducted with a total of 18 healthcare providers who mostly practiced in primary care or emergency department settings in rural areas. Providers were asked about common mechanisms of TBI in patients that they treat, challenges they face in initial and follow-up care, and opportunities for improvement in their practice.

RESULTS

The rural healthcare providers reported that common mechanisms of injury included sports-related injuries for their pediatric and adolescent patients and work-related accidents, motor vehicle crashes, and falls among their adult patients. Most providers felt prepared to diagnose and manage their patients with TBI, but acknowledged a series of challenges they face, including pushback from parents, athletes, and coaches and lack of specialists to whom they could refer. They also noted that patients had their own barriers to overcome for timely and adequate care, including lack of access to transportation, difficulties with cost and insurance, and denial about the seriousness of the injury. Despite these challenges, the focus group participants also outlined benefits to practicing in a rural area and several ways that their practice could improve with support.

CONCLUSION

Rural healthcare providers may be comfortable diagnosing, treating, and managing their patients who present with a suspected TBI, but they also face many challenges in their practice. In this study it was continually noted that there was lack of resources and a lack of awareness, or recognition of the seriousness of TBI, among the providers' patient populations. Education about common symptoms and the need for evaluation after an injury is needed. The use of telemedicine, an increasingly common technology, may help close some gaps in access to services. People living in rural areas may be at increased risk for TBI. Healthcare providers who work in these areas face many challenges but have found ways to successfully manage the treatment of this injury in their patients.

Community-Level Social Determinants of Health and Well-Child Visits Among Alabama Medicaid Enrollees

Well-child visits focus on health promotion and disease detection and are critical to the appropriate provision of care. Evidence has shown that participation in well-child visits is associated with various patient-level factors; however, there has been an increasing focus on the influence of community-level social determinants of health (SDoH). This study explored associations between well-child visits and community-level SDoH at the census tract level among children enrolled in Alabama Medicaid. Through this analysis, it is possible to understand the distribution of care among this underserved population in different geographic settings, thus identifying potential disparities and areas for targeted intervention. Using administrative data from 2015 to 2017 enrollees in Alabama Medicaid that have been geographically linked to information on urbanicity and poverty, logistic regressions (both in total and stratified by age group) were estimated with separate community-level urbanicity, poverty variables, and individual characteristics. The regressions were repeated using a combined urbanicity/poverty variable. Looking at urbanicity and poverty together, with the exception of the least urban areas, it was those living in census tracts where there was discordance in urbanicity and poverty that had the highest likelihood of receiving well-child visits compared with those in census tracts classified as medium poverty (all urbanicity levels). There is a positive effect for Medicaid enrollees in the middle tertile of urbanicity in areas of low and high poverty and in wealthier more urban areas. If poverty and urbanicity were explored separately, some of the nuances would not have been apparent.

Traumatic Brain Injury-Related Hospitalizations and Deaths in Urban and Rural Counties-2017

STUDY OBJECTIVE

A better understanding of differences in traumatic brain injury incidence by geography may help inform resource needs for local communities. This paper presents estimates on traumatic brain injury-related hospitalizations and deaths by urban and rural county of residence.

METHODS

To estimate the incidence of traumatic brain injury-related hospitalizations, data from the 2017 Healthcare Cost and Utilization Project's National Inpatient Sample were analyzed (n=295,760). To estimate the incidence of traumatic brain injury-related deaths, the Centers for Disease Control and Prevention's National Vital Statistics System multiple-cause-of-death files were analyzed (n=61,134). Datasets were stratified by residence, sex, principal mechanism of injury, and age group. Traumatic brain injury-related hospitalizations were also stratified by insurance status and hospital location.

RESULTS

The rate of traumatic brain injury-related hospitalizations was significantly higher among urban (70.1 per 100,000 population) than rural residents (61.0), whereas the rate of traumatic brain injury-related deaths was significantly higher among rural (27.5) than urban residents (17.4). These patterns held for both sexes, individuals age 55 and older, and within the leading mechanisms of injury (ie, suicide, unintentional falls). Among patients with Medicare or Medicaid, the rate of traumatic brain injury-related hospitalizations was higher among urban residents; there was no urban/rural difference with other types of insurance. Nearly all (99.6%) urban residents who were hospitalized for a traumatic brain injury received care in an urban hospital. Additionally, approximately 80.3% of rural residents were hospitalized in an urban hospital.

CONCLUSION

Urban residents had a higher rate of traumatic brain injury-related hospitalizations, whereas rural residents had a higher rate of traumatic brain injury-related deaths. This disparity deserves further study using additional databases that assess differences in mechanisms of injury and strategies to improve access to emergency care among rural residents.

Professional stakeholders' perceptions of barriers to behavioral health care following pediatric traumatic brain injury

OBJECTIVE

To examine professional stakeholders' perspectives of barriers to behavioral health care (BHC) follow-up and telepsychology after pediatric traumatic brain injury (TBI).

METHODS

Twenty-nine professionals participated in a focus group (FG) or key informant interview (KII) between January and March 2020. Professionals answered questions about facilitators and barriers to BHC follow-up and telepsychology. Given widespread telepsychology implementation since COVID-19, a follow-up survey assessing telehealth perceptions since the pandemic was sent out in December 2020. Nineteen professionals completed the survey.

RESULTS

Professionals identified individual (e.g., family factors, insurance coverage/finances, transportation/distance, availability, planning follow-up care) and system-level (e.g., lack of access to BHC providers) barriers to BHC post-injury. Possible solutions, like collaborative follow-up care, were also identified. Generally, clinical professionals have favorable impressions of telepsychology and utilized services as a delivery modality for clinical care. Though telepsychology could reduce barriers to care, professionals also expressed concerns (e.g., technology issues, security/safety) and challenges (e.g., funding, accessibility, training/licensure for clinicians) with implementing telepsychology.

CONCLUSION

Barriers identified highlight the need for context-specific solutions to increase BHC access, with telepsychology generally recognized as a beneficial modality for BHC. Future work should continue to focus on understanding barriers to BHC and potential solutions after pediatric TBI.

Measuring the effects of institutional pediatric traumatic brain injury volume on outcomes for rural-dwelling children

OBJECTIVE

Rural-dwelling children may suffer worse pediatric traumatic brain injury (TBI) outcomes due to distance from and accessibility to high-volume trauma centers. This study aimed to compare the impacts of institutional TBI volume and sociodemographics on outcomes between rural- and urban-dwelling children.

METHODS

This retrospective study identified patients 0-19 years of age with ICD-9 codes for TBI in the 2012-2015 National Inpatient Sample database. Patients were characterized as rural- or urban-dwelling using United States Census classification. Logistic and linear (in log scale) regressions were performed to measure the effects of institutional characteristics, patient sociodemographics, and mechanism/severity of injury on occurrence of medical complications, mortality, length of stay (LOS), and costs. Separate models were built for rural- and urban-dwelling patients.

RESULTS

A total of 19,736 patients were identified (median age 11 years, interquartile range [IQR] 2-16 years, 66% male, 55% Caucasian). Overall, rural-dwelling patients had higher All Patient Refined Diagnosis Related Groups injury severity (median 2 [IQR 1-3] vs 1 [IQR 1-2], p < 0.001) and more intracranial monitoring (6% vs 4%, p < 0.001). Univariate analysis showed that overall, rural-dwelling patients suffered increased medical complications (6% vs 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1-4 days ] vs 2 days [IQR 1-3 days], p < 0.001), but multivariate analysis showed rural-dwelling status was not associated with these outcomes after adjusting for injury severity, mechanism, and hospital characteristics. Institutional TBI volume was not associated with medical complications, disposition, or mortality for either population but was associated with LOS for urban-dwelling patients (nonlinear beta, p = 0.008) and cost for both rural-dwelling (nonlinear beta, p < 0.001) and urban-dwelling (nonlinear beta, p < 0.001) patients.

CONCLUSIONS

Overall, rural-dwelling pediatric patients with TBI have worsened injury severity, mortality, and in-hospital complications, but these disparities disappear after adjusting for injury severity and mechanism. Institutional TBI volume does not impact clinical outcomes for rural- or urban-dwelling children after adjusting for these covariates. Addressing the root causes of the increased injury severity at hospital arrival may be a useful path to improve TBI outcomes for rural-dwelling children.

Rural Primary Care Providers' Experience and Usage of Clinical Recommendations in the CDC Pediatric Mild Traumatic Brain Injury Guideline: A Qualitative Study

PURPOSE

In 2018, the Centers for Disease Control and Prevention (CDC) released an evidence-based guideline on pediatric mild traumatic brain injury (mTBI) to educate health care providers on best practices of mTBI diagnosis, prognosis, and management/treatment. As residents living in rural areas have higher rates of mTBI, and may have limited access to care, it is particularly important to disseminate the CDC guideline to rural health care providers. The purpose of this paper is to describe rural health care providers' experience with pediatric mTBI patients and their perceptions on incorporating the guideline recommendations into their practice.

METHOD

Interviews with 9 pediatric rural health care providers from all US regions were conducted. Interview transcripts were coded and analyzed for themes for each of the main topic areas covered in the interview guide.

FINDINGS

Common causes of mTBI reported by health care providers included sports and all-terrain vehicles. While health care providers found the guideline recommendations to be helpful and feasible, they reported barriers to implementation, such as lack of access to specialists. To help with uptake of the CDC guideline, they suggested the development of concise implementation tools that can be referenced quickly, integrated into electronic health record-based systems, and that are customized by visit type and health care setting (eg, initial vs follow-up visits and emergency department vs primary care visits).

CONCLUSION

Length, accessibility, and usability are important considerations when designing clinical tools for busy rural health care providers caring for pediatric patients with mTBI. Customized information, in both print and digital formats, may help with uptake of best practices.