- Email: [email protected]
Hospital-Based Health Care After Traumatic Brain Injury
Accepted Manuscript Hospital-based health care after traumatic brain injury David Salisbury, Psy.D., Simon J. Driver, Ph.D, Megan Reynolds, M.S., Monica Bennett, Ph.D., Laura B. Petrey, M.D, Anne Marie Warren, Ph.D PII:
S0003-9993(16)31140-6
DOI:
10.1016/j.apmr.2016.09.117
Reference:
YAPMR 56689
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 23 March 2016 Revised Date:
29 August 2016
Accepted Date: 11 September 2016
Please cite this article as: Salisbury D, Driver SJ, Reynolds M, Bennett M, Petrey LB, Warren AM, Hospital-based health care after traumatic brain injury, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.09.117. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Running head: HEALTH CARE AND TBI Title: Hospital-based health care after traumatic brain injury
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Authors: David Salisbury, Psy.D.1, Simon J. Driver, Ph.D1, Megan Reynolds, M.S. 1,Monica
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Bennett, Ph.D.2., Laura B. Petrey, M.D2., and Anne Marie Warren, Ph.D2. Affiliated institutions: 1Baylor Institute for Rehabilitation, Dallas;
Baylor Scott & White,
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Dallas.
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Acknowledgement of presentation of material: Some of the data from this paper were presented at the American Congress of Rehabilitation Medicine Meeting in Dallas (2015). Acknowledgement of financial support: The project was supported by the Ginger Murchison
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Foundation Traumatic Brain Injury Research Fund. The contents of this manuscript were also developed under a grant from the National Institute on Disability, Independent Living, and
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Rehabilitation Research (NIDILRR grant number 90DP0045-01-0). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services
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(HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. Conflict of Interest: No conflicts were endorsed by the authors. Correspondence concerning this article should be addressed to David B. Salisbury, Department of Neuropsychology, Baylor Institute for Rehabilitation, 411 N. Washington Ave., Suite 5000, Dallas, Texas, 75246. Phone: 214.820.7964. E-mail: [email protected]
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Hospital-based Health Care after Traumatic Brain Injury
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Abstract
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Objective: To investigate trends of hospital-based health care utilization after admission to a
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Level 1 trauma center following acute traumatic brain injury (TBI).
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Design: Retrospective review.
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Setting: Large urban trauma hospital and a hospital council data registry consisting of 88
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member institutions (>150 hospitals) covering 15,000 square miles.
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Participants: All patients admitted to a Level I trauma center between January 2006 - June 2014
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who experienced an acute TBI based on ICD-9 coding.
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Intervention: Not applicable.
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Main Outcome Measures: Included the incidence and type of select hospital-based services
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received. Analyses were also categorized based on demographic and injury-related information.
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Results: There were 5,291 patients with newly acquired TBI admitted; 512 died, leaving 4,779
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patients for inclusion into the final analysis. Additional healthcare utilization from January 2006-
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June 2014 was recorded for 3,158 patients (66%), totaling 12,307 encounters with a median of 3
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encounters (IQR: 1-5), and a maximum of 102 encounters. The vast majority of non-admission
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urgent or procedural visits (96%) and inpatient encounters (93%) occurred in the first year. Of all
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the additional encounters, 9,769 visits were non-admission urgent or procedural visits (79%)
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with a median charge of $1,955, and most common type of encounter being elective (46%),
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followed by medical emergency (29%). Of the remaining 2,538 (21%) inpatient encounters, the
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mean length of stay was 6 days with median charge of $28,450, and medical emergency (39%)
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and elective admissions (33%) again being the most common encounter type.
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Conclusions: This analysis encompasses healthcare utilization across the range of TBI severity
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and numerous hospital systems allowing for a more comprehensive and objective identification
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of reasons for readmission. This represents an initial step to developing a preventative
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intervention to manage secondary complications post-injury.
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Key Words: TBI, readmissions, outcomes
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In the ever-changing culture of healthcare, an emphasis upon identification and tracking of
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potentially preventable and often costly medical complications has garnered significant interest.
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This focus will only intensify as hospitals are mandated to make readmission rates publically
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available for various medical conditions and financial penalties are mandated for specific types
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of readmission by common payer sources such as Medicare and Medicaid 1,2. The increasing use
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and ultimate integration of large electronic medical record databases will likely play a
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determining role in shaping policy and practice related to preventative and primary healthcare
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practices.
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The application of comprehensive and longitudinal databases would be beneficial for neurorehabilitation populations such as traumatic brain injury (TBI) where follow-up care may
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occur across the lifespan. In fact, conceptualizing moderate to severe TBI as a chronic condition
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has been advocated by some groups 3,4. This potential paradigm shift is based on the support for
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longstanding risks of increased morbidity (e.g., diabetes, hypertension), mortality, as well as the
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chronic cognitive and psychological sequelae that can accompany some survivors of TBI 4,5.
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Hence, the impact of moderate to severe TBI can be seen as an evolving process that has
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pervasive effects on the survivor, family, community, and society as a whole 3,6. This revised
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outlook upon moderate to severe TBI would align with the need to adopt a chronic care model of
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treatment which has been shown to be effective across various medical conditions 7,8.
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The impetus to improve management of TBI becomes even more pressing when
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considering the global estimates of up to 10 million individuals impacted yearly9,10. Trends
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within the United States (U.S.) show TBI to be a primary or secondary diagnosis in 2-3.5 million
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yearly emergency department visits, hospitalizations and deaths 11,12. The vast majority of
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individuals diagnosed with TBI sustain a mild TBI/concussion 11,13-15. Within the subgroup of 4
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people with mild TBI without additional complications, there is a good prognosis for rapid
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recovery to prior functioning and increased use of health-care services would not be expected 16-
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problems and can be at risk for future health care services. For those with complicated recoveries
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extending beyond three months, numerous secondary factors such as litigation, substance abuse,
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medical and psychiatric history have been suggested to play a role 18-22
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. Controversy remains about the clear minority of mild TBI patients who report persistent
The increased TBI-related emergency room visits and decline in TBI-related deaths (e.g. 19.9 per 100,000 in 1995 to 16.6 per 100,000 in 2009) foreshadow a greater societal burden to
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provide appropriate treatment in the decades to come12. Prior studies have suggested
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rehospitalization rates from 20-28% in the first year after moderate to severe traumatic brain
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injury with initial readmissions often being elective (e.g., orthopedic, reconstructive procedures),
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while utilization across-time has been linked to medical comorbidites, infection, seizures and
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behavioral/psychiatric reasons 23-30. Ma et al (2014) 31summarized TBI studies in the U.S.
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focused on societal impact to conclude that direct costs may reach $13.1 billion and indirect cost
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could exceed 64 billion.
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However, there are many barriers to better understanding the complications of TBI
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including a lack of integrated health records, limited generalizability of studies focused on
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specific subgroup of TBI survivors, reliance upon self-report of post-TBI complications, and
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challenges of interpreting studies based on differing health care systems 28,32. This study attempts
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to address limitations of previous studies that have used selective and non-generalizable patient
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samples by combining trauma and regional registry datasets from a large metropolitan area. The
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primary aim is to clarify the frequency and characterize the nature of health care utilization
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across the continuum of TBI severity with a very diverse sample. A secondary aim is the
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identification of individuals at risk for high health care utilization after the initial TBI as this
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target group may be ideal for preventative interventions.
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Methods
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Procedure
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Following approval from the institutional review board, a single Level 1 trauma Center registry
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was combined with the Dallas-Fort Worth Hospital Council Foundation (DFWHCF) utilization
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data from January 2006-June 2014 and. Specifically, this retrospective cross-sectional design
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involved patients who experienced a TBI during their index as determined by Codes from the
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International Classification of Disease – 9th Edition (ICD-9) (i.e., 800-804 with .0 and .5
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excluded, and 850-854).
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The large trauma center in the Southwest United States admits approximately 2,500 patients annually, including 650-700 individuals with TBI. The combined database allowed us to
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track the frequency and nature of healthcare utilization across time. The DFWHCF collects data
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from 88 member institutions (>150 hospitals), including more than 96% of all hospital
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discharges across 15,000 square miles of North Texas. Institutions submitting data to the
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DFWHCF include three Level I trauma centers, three level II centers, and five Level III centers.
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Data from the DFWHCF includes hospital admissions and non-admission emergent or
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procedural visits. More specifically this data captures a variety of services such as ambulatory
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surgery, emergency department visits, observation, radiology and cardiac catherization.
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Outpatient laboratory visits and hospital-based outpatient clinic visits are not included in the
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database. This data is collapsed into broader categorizations, based on state reporting 6
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requirements, primarily linked to the physician specialty or procedure, thus specific analysis on
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multidisciplinary services provided was not available. Skilled nursing facilities (SNFs) and
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long-term acute care hospitals (LTACs) were not included in this analysis as few facilities have
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historically contributed data to the DFWHCF, limiting any meaningful analysis.
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Data
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Variables queried from the trauma registry and DFWHCF included (1) demographic information
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(e.g., age, gender, race, ethnicity, insurance type), (2) duration of loss of consciousness (<1 hour;
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1-24 hours; and >24 hours) , (3) healthcare utilization data (e.g., diagnosis codes, inpatient
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procedures, dates of admission and discharge, discharge disposition, date(s) of utilization,
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primary and secondary diagnoses, and principal procedures) and (4) 3M™ All Patient Refined
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Diagnosis Related Group (APR DRGs) used by DFWHCF to measure burden of illness (for
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additional information about the development and validity of this tool please see
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http:www.#Mhis.com and the white paper referenced) 33. The 3M™ variable classifies severity
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of index admissions based on diagnoses and procedure performed with subclasses including:
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minor, moderate, major and extreme. These numerical values do not represent scores but a
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continuum based on algorithms that account for the interaction between factors such as age,
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gender, chronic condition(s) severity, co-morbidities, nature and likely duration of
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complications, potential resource utilization and mortality risk. The DRGs have been validated
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with national data and were implemented in the 1990s. Individuals in the higher severity
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classifications typically have a worse prognosis due to the presence of multiple conditions
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impacting numerous organ systems. This system is analogous to the Centers for Medicare and
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Medicaid Severity Diagnosis Related Groups and used by numerous health plans, state agencies,
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accountable care organizations and providers.
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Statistical Analysis
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All data were summarized using standard descriptive statistics. Mean and standard deviation or
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median and interquartile range were used for quantitative variables, and counts and percentages
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were used for all qualitative variables. In an effort to identify superutilizers of health care after
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the initial TBI, we focused upon the subgroup of the sample at the 75th percentile for both
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inpatient and non-admission urgent or procedural visits coded as medical emergency, urgent, or
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trauma related. Two such encounters fell at the 75th percentile. Patients who had three or more
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encounters in year following index admission were labeled as superutilizers. Multiple logistic
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regression was used to determine which factors were associated with being in the super-utilizer
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group.
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Results
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Subjects and Index Admission Characteristics
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Between January 1, 2006 and June 30, 2014, 16,717 individuals were admitted to the institution
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with a traumatic injury (Figure 1). We identified 5,291patients age 18 and older with index
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trauma admissions of TBI. Of these, 512 patients died during their index admission and were
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excluded from analysis, accounting for a final total of 4,779 patients with TBI.
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Demographic and clinical information for the original trauma admission is presented in
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Table 1. Mean age of the final sample of TBI patients (N=4,779) was 50.6 (±21.9), with the
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majority male (65%) and Caucasian (59%), which is consistent with the overall injured patient
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population at the trauma center. At index admission, 67% of patients did not have private
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insurance. Median length of stay (LOS) for index admissions was 5 days, accounting for a
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median cost of $36,100 in charges. The only acute indicator of TBI severity that was captured consistently enough to be
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meaningfully interpreted was loss of consciousness. Of those who could be classified, the
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majority (60%) were documented as having less than one hour loss of consciousness. As
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expected, the median LOS dramatically jumped when loss of consciousness increased from less
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than one hour (LOS = 4 days) to 1-24 hours (LOS = 21 days) or greater than 24 hours (LOS = 29
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days) (Table 2).
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The ten most frequent ICD-9 codes documented for initial hospitalization are presented in Table 3. The broad 3M™ DRG categorization demonstrated that median LOS and hospital
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charges consistently increased across the severity categories (Table 4). Among the sample, 85%
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of individuals’ severity of index admission was rated as moderate to extreme.
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Characteristics of Additional Healthcare Utilization
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Of the 4,779 TBI patients included in the sample, 66% (n=3,158) had additional healthcare
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utilization beyond their index admission, accounting for 12,307 total additional patient
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encounters (Figure 1). The length of time followed post-discharge from acute hospitalization
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varied given the initial injury date for patients with a range of 0-8.5 years, mean of 4.2 (+2.4
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years) and median (Q,1 Q3) of 4.2 years (2.2, 6.2). Of the total additional patient encounters,
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79% (n= 9,769) were non-admission urgent or procedural visits and 21% were inpatient
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(n=2538). The median number of additional visits was 3 (IQR: 1-5), with a maximum number of
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102 additional encounters. There was also a decrease in the frequency of admissions over time
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(Figure 2). In the first year post-injury most non-admission urgent or procedural visits (96%) and
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inpatient encounters (93%) occurred. By the second year, non-admission urgent or procedural
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visits (2.0%) and inpatient encounters (3.4%) dramatically decreased with a further trend of
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decline in subsequent years.
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The median charge for a non-admission urgent or procedural visit was $1,955. Of these visits, 46% were elective in nature, while 29% were listed as medical emergencies or urgent. The
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overall median charge was greatly impacted by those cases involving associated procedural
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codes (e.g. injections, surgery), most often seen among visits classified as medical emergencies
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or urgent. For these cases, the median charge was $4,540. Among non-admission urgent or
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procedural visits, the top specializations involved included emergency medicine (20%),
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specialists (9%), and physical medicine and rehabilitation (8%), neurological surgery and
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internal medicine (7% each). The most common ICD-9 codes documented were essential
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hypertension (18%), nondependent abuse of drugs (14%) with the majority being tobacco
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related, and diabetes mellitus (9%) (Table 3).
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The median charge for an inpatient stay was $28,450, with a median LOS of 6 days. The
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encounters were often medical emergencies (39%), elective (33%) or urgent (24%). The top
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specializations involved included internal medicine (30%), trauma surgery (8%), hospitalists
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(7%) and physical medicine and rehabilitation (6%). Among this subsample, the most frequently
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documented ICD-9 codes were disorders of fluid electrolytes and acid-base balance (50%),
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essential hypertension (46%), diabetes mellitus (30%) and unspecified anemia (29%).
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Nondependent abuse of drugs (27%), primarily related to tobacco use, and persistent mental
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disorders due to conditions classified elsewhere (23%) were also common reasons for utilization
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(Table 3).
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Patients who had three or more encounters in year following index admission (N = 1021) were labeled as superutilizers. Demographic information for TBI patients stratified by
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superutilizers is presented in Table 5. A review of demographics indicated that a significantly
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greater number of females (p<.0001), African Americans (p<.0001), and individuals without
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private insurance (p<.0001) were in the superutilization group. While no difference in utilization
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was found based on loss of consciousness, a significantly greater number of individuals
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classified as extreme (p=0.0298) based on the 3MTM severity score were superutilizers.
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Superutilizers were significantly less likely to be discharged home (47% vs. 69%) and
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significantly more likely to transition to rehabilitation care (20% vs. 14%; p<.0001), LTAC
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facilities (6% vs. 1%; p<.0001) or SNF (16% vs. 10%; p = .004).
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superutilizers were 2.1 times greater ($97,781,753 vs. $46,691,604) than the total charges of all
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other patients. This charge differential may be explained by the increased length of stay and
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greater medical complexity (per the 3M™ DRG categorization) among the superutilization
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group. The primary diagnosis and distribution for inpatient readmissions and non-admission
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urgent or procedural visits for the superutilizers was surprisingly similar to that of the general
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sample.
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Discussion
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Findings from this regional database represent a platform to better understand care utilization
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after TBI. The preponderance of medical care utilized within the first year after injury has been
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detailed in prior samples, but the surprisingly low rate of care utilization after the first year is
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well below that of prior studies 23,28,29. Most likely, the inclusion of all TBI severity levels
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resulted in a larger portion of milder injuries. Mild TBI is not expected to be linked to increased
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future medical encounters after discharge unless there are additional medical complications.
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The total charges for high
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Approximately half of our probable mild TBI patients had lower global injury severity rating
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based on 3M™ DRG categorization. Hence, this subgroup unlikely had significant medical
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complications that would necessitate extensive future care. Considering the higher percentage of
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minority patients in our sample as compared to prior studies 25,34,35, this database may lend itself
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to better understanding previously raised concerns in the literature regarding post-injury
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outcome after moderate-severe traumatic brain injury. Level of care in the emergency room,
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access to inpatient rehabilitation and specialized outpatient care has been discrepant for some
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minority populations impacting outcome even when accounting for demographic and severity of
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injury 36-40. It will be important to rule out access to primary and specialized care when further
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considering care utilization trends. Given the ability to capture rehospitalizations over a large
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catchment area outside of the admission hospital system, it is unlikely that the low rates of care
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utilization solely reflect missed contacts seen in other systems.
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Attempts to characterize the nature of health care utilization were based on broad
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categorization of primary services sought and ICD-9 codes. Similarities were noted across
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inpatient and non-admission urgent or procedural visits. However, inpatient encounters were
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more often related to medical emergencies with a relatively comparable percentile of elective
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admissions whereas elective admissions dominated non-admission urgent or procedural visits.
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The most prevalent ICD-9 codes recorded after index admission were notable for potentially
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treatable comorbidities (e.g. disorders of fluid electrolytes, diabetes mellitus, and hypertension).
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This promising finding further supports the possibility of enhanced discharge planning and
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preventative care strategies to decrease medical care needs after TBI.
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Further analysis of a subgroup of superutilizers focused on encounters only in the year after injury. Given the dramatic decline in health care accessed after the first year, this first year 12
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time frame likely captures the window of opportunity for preventative interventions and better
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management of health care costs. Superutilizers accounted for over twice the charges of the
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whole sample, while consisting of only 21% of the study population. As expected, general injury
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severity was higher in this subgroup which required longer stays and were less likely discharged
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home after the index injury. However, the reason for future inpatient and non-admission urgent
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or procedural visits in this group mirrored the larger sample. Furthermore, a comparison of
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patient specific variables yielded only a few primary differences with regards to ethnicity and
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insurance type. Still, this subgroup remains a priority for further research. Additional variables
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such as appropriate post-discharge follow-up and preventative care along with patient health
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literacy are not available in the broader database and could fuel the care need discrepancy with
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this subgroup.
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Study Limitations
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Limitations in the current analysis are readily acknowledged. Specifically, these results include
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patients with TBI originally admitted to a single trauma center and do not reflect a population-
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based sample. Similarly, this data is composed of administrative data collected from both trauma
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and non-trauma centers, which may affect how data was abstracted. In addition, it is nearly
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impossible to determine if the 34% of individuals without healthcare utilization post-TBI
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remained within the region served by DFWHCF and did not require utilization, or if the
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individuals relocated to outside of the region or expired. Nevertheless, the information provided
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by the DFWHCF represents a vast improvement over data reliant upon a single healthcare
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facility/system, subgroup of patients with TBI, or self-reported data.
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The database variables to clarify traumatic brain severity information were also limited. As previously mentioned, the database used duration of loss of consciousness (<1 hour; 1-24
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hours, 24+ hours) that differed from typical clinical categorizations that often identify the mildest
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injuries as involving loss of consciousness below thirty minutes. This prohibits a more traditional
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demarcation of mild, moderate and severe TBI categorization based on loss of consciousness. Of
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those who could be classified, the majority (60%) were documented as having less than one hour
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LOC. Thirty-six percent of patients were grouped as unspecified TBI severity given the lack of
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loss of consciousness information that could be obtained. When comparing the group with
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unspecified duration loss of consciousness to all others, the unspecified group was very similar
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to the less than one hour loss of consciousness group in regards to LOS, typical hospital charges
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and general severity data. This would suggest that the unspecified category primarily included
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individuals who sustained the mildest level of TBI.
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When reviewing the patient discharge information, superutilizers are found to be more
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commonly discharged to LTAC or SNF facilities. Of note though, the database does not clarify
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the number of patients admitting from a LTAC or SNF initially.
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particularly age, similarities between the superutilizer group and the larger sample would not
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suggest that premorbid residence for this group was more likely in a SNF or a LTAC facility but
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this will require further analyses outside the scope of this dataset.
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The demographic, and
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Finally, the inability to capture hospital-based outpatient clinic visits within the larger
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database must be reiterated. This likely underestimated the subsequent care received after TBI in
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our sample. The decision to omit SNF and LTAC settings was again primarily based on the
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limited number of facilities that contribute to the database. A future focus on this subgroup may
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be possible as a current project is under way to create a separate database to capture health care
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utilization in SNF and LTAC.
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Conclusions
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The ultimate goal of preventative interventions to better manage TBI and minimize future health
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complications requires a clearer understanding of frequent complications post injury. This study
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represents an initial analysis of trends using a regional database that allows for tracking of health
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care utilization following TBI across healthcare systems. The data suggests that potentially
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treatable comorbidities such as electrolyte imbalance, diabetes mellitus, and hypertension could
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be prime targets for patient or family interventions after TBI.
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References
rates of readmissions. N Engl J Med. 2009;361(27):2637-2645. 2. Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM.
RI PT
1. Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and
Determinants of preventable readmissions in the united states: A systematic
SC
review. Implement Sci. 2010;5:88-88.
3. Corrigan J, D., Hammond F, M. Traumatic brain injury as a chronic health
M AN U
condition. Arch Phys Med Rehabil. 2013;94(6):1199-1201.
4. Masel BE, DeWitt DS. Traumatic brain injury disease: Long-term consequences of traumatic brain injury. In: Levin HS, Shum DHK, Chan RCK, Levin HS(, Shum DHK(, Chan RCK(, eds. New York, NY, US:
TE D
Oxford University Press; 2014:28-53.
http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=201440048-003&site=eds-live&group=test.
EP
5. Chauhan NB. Chronic neurodegenerative consequences of traumatic brain injury. Restor Neurol Neurosci. 2014;32(2):337-365.
AC C
6. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury. J Head Trauma Rehabil. 2006;21(5):375-378. 7. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2-4. 8. Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Effectiveness of chronic care models: Opportunities for improving healthcare practice and
16
ACCEPTED MANUSCRIPT Running head: HEALTH CARE AFTER TBI
health outcomes: A systematic review. BMC Health Services Research. 2015;15(1):1-11. 9. Humphreys I(1), Phillips CJ(1), Wood RL(2), Macey S(3). The costs of
Research. 2013;5(1):281-287.
RI PT
traumatic brain injury: A literature review. ClinicoEconomics and Outcomes
10. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye
NeuroRehabilitation. 2007;22(5):341-353.
SC
OC. The impact of traumatic brain injuries: A global perspective.
M AN U
11. Centers for Disease Control and Prevention (CDC). Report to Congresstraumatic brain injury in the united states: epidemiology and rehabilitation .
TBI_Report_to_Congress_Epi_and_Rehab Web site.
TE D
http://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_ and_Rehab-a.pdf. Accessed August 24, 2015.
12. Coronado VG, McGuire LC, Sarmiento K, et al. Trends in traumatic
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brain injury in the U.S. and the public health response: 1995–2009. J Saf Res. 2012;43(4):299-307.
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13. Coronado V, G., Haileyesus T, Cheng T, A., et al. Trends in sports- and recreation- related traumatic brain injuries treated in US emergency departments: The national electronic injury surveillance system-all injury program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil. 2015;30(3):185197. 14. Marin JR, Weaver MD, Yealy DM, Mannix RC. Trends in visits for
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traumatic brain injury to emergency departments in the United States. JAMA. 2014;311(18):1917-1919. 15. Rutland-Brown W, Langlois JA, Thomas KE, Xi YL. Incidence of
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traumatic brain injury in the United States, 2003. J Head Trauma Rehabil. 2006;21(6):544-548.
16. Babikian T, Asarnow R. Neurocognitive outcomes and recovery after
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pediatric TBI: Meta-analytic review of the literature. Neuropsychology. 2009;23(3):283-296.
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17. Nelson LD, Janecek JK, McCrea MA. Acute clinical recovery from sportrelated concussion. Neuropsychol Rev. 2013;23(4):285-299.
18. Rohling ML, Binder LM, Demakis GJ, Larrabee GJ, Ploetz DM, Langhinrichsen-Rohling J. A meta-analysis of neuropsychological outcome
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after mild traumatic brain injury: Re-analyses and reconsiderations of Binder et al. (1997), Frencham et al. (2005), and Pertab et al. (2009). Clin Neuropsychol. 2011;25(4):608-623.
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19. Belanger HG, Curtiss G, Demery JA, Lebowitz BK, Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic
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brain injury: A meta-analysis. J Int Neuropsychol Soc. 2005;11(3):215-227. 20. Karr JE, Areshenkoff CN, Garcia-Barrera M. The neuropsychological outcomes of concussion: A systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. Neuropsychology. 2014;28(3):321-336. 21. King NS. A systematic review of age and gender factors in prolonged
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post-concussion symptoms after mild head injury. Brain Injury. 2014;28(13):1639-1645. 22. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A,
traumatic brain injury. Neuropsychology. 2012;26(3):304-313.
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Schönberger M. Predictors of postconcussive symptoms 3 months after mild
23. Cifu DX, Kreutzer JS, Marwitz JH, et al. Etiology and incidence of
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rehospitalization after traumatic brain injury: A multicenter analysis. Arch Phys Med Rehabil. 1999;80(1):85-90.
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24. Corrigan JD, Horn SD, Barrett RS, et al. Effects of patient preinjury and injury characteristics on acute rehabilitation outcomes for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8, Supplement):S209-S221.e6. 25. Hammond FM, Horn SD, Smout RJ, et al. Rehospitalization during 9
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months after inpatient rehabilitation for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8, Supplement):S330-S339.e4. 26. Kayani NA, Homan S, Yun S, Zhu BP. Health and economic burden of
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traumatic brain injury: Missouri, 2001-2005. Public Health Rep. 2009;124(4):551-560.
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27. Leibson CL, Brown AW, Hall Long K, et al. Medical care costs associated with traumatic brain injury over the full spectrum of disease: A controlled population-based study. J Neurotrauma. 2012;29(11):2038-2049. 28. Marwitz JH, Cifu DX, Englander J, High WM, J. A multi-center analysis of rehospitalizations five years after brain injury. J Head Trauma Rehabil. 2001;16(4):307-317.
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29. Prang K, Ruseckaite R, Collie A. Healthcare and disability service utilization in the 5-year period following transport-related traumatic brain injury. Brain Inj. 2012;26(13-14):1611-1620.
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30. Tuominen R, Joelsson P, Tenovuo O. Treatment costs and productivity losses caused by traumatic brain injuries. Brain Injury. 2012;26(13):16971701.
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31. Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the united
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states: Stroke, spinal cord injury, traumatic brain injury, multiple sclerosis,
osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil. 2014;95(5):986-995.e1.
32. Stroupe K, T., Smith B, M., Hogan T, P., et al. Healthcare utilization and
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costs of veterans screened and assessed for traumatic brain injury. J Rehabil Res Dev. 2013;50(8):1047-1068.
33. Averill RF, Goldfield NI, Eisenhandler J. et al. development and
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evaluation of the clinical risk groups (CRGS).. 1999(Final Report to the National Institutes of Standards and Technology, US Department of
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Commerce).
34. Corrigan JD, Selassie AW, Lineberry LA, et al. Comparison of the traumatic brain injury (TBI) model systems national dataset to a populationbased cohort of TBI hospitalizations. Arch Phys Med Rehabil. 2007;88(4):418-426. 35. Cuthbert JP, Corrigan JD, Whiteneck GG, et al. Extension of the
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representativeness of the traumatic brain injury model systems national database: 2001 to 2010. J Head Trauma Rehabil. 2012;27(6):E15-E27. 36. Bowman SM, Martin DP, Sharar SR, Zimmerman FJ. Racial disparities
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in outcomes of persons with moderate to severe traumatic brain injury. Med Care. 2007;45(7):686-690.
37. Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences
literature. Brain Inj. 2009;23(10):775-789.
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exist in post-injury outcomes after TBI? A comprehensive review of the
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38. Kane WG, Wright DA, Fu R, Carlson KF. Racial/ethnic and insurance status disparities in discharge to posthospitalization care for patients with traumatic brain injury. J Head Trauma Rehabil. 2014;29(6):E10-7.
39. Shafi S, Marquez de la Plata C, Diaz-Arrastia R, et al. Racial disparities
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in long-term functional outcome after traumatic brain injury. J Trauma. 2007;63(6):1263-8; discussion 1268-70.
40. Shafi S, de lP, Diaz-Arrastia R, et al. Ethnic disparities exist in trauma
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care. J Trauma. 2007;63(5):1138-1142. 289
Figure Legend
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Figure 1: Healthcare utilization between January 2006 and June 2014
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Figure 2: Healthcare encounters within one year of injury
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Table 3. Top ICD-9 codes for hospitalization among TBI patients
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Top ICD-9 Codes for Initial Hospitalization 1. 276 – Disorders of fluid electrolyte and acid-base balance 276.8 - Hypopotassemia 2. 305 – Nondependent abuse of drugs 305.1 – Tobacco use disorder 3. 852 – Subarachnoid subdural and extradural hemorrhage following injury 852.2 – Subdural hemorrhage following injury w/o mention of open intracranial wound 4. 802 – Fracture of face bones 802.0 – Closed fracture of nasal bones 5. 401 – Essential hypertension 401.9 – Unspecified essential hypertension 6. 873 – Other open wound of head 873.0 – Open wound of scalp, w/o mention of complication 7. 805 – Fracture of vertebral column without mention of spinal cord injury 805.4 – Closed fracture of lumbar vertebra without mention of spinal cord injury 8. 801 – Fracture of base of skull 801.26 – Closed fracture of base of skull w/ subarachnoid, subdural, extradural hemorrhage 9. 518 – Other diseases of lung 518.81 – Acute respiratory failure 10. 285 – Other and unspecified anemias 285.1 – Acute posthemorrhagic anemia Top ICD-9 Codes for non-admission urgent or procedural visits 1. 401 – Essential hypertension 401.9 – Unspecified essential hypertension 2. 305 – Nondependent abuse of drugs 305.1 – Tobacco use disorder 3. 780 – General symptoms 780.39 – Other convulsions 4. 250 – Diabetes mellitus 250.0 – Diabetes mellitus without mention of complication 5. 786 – Symptoms involving respiratory system and other chest symptoms 786.5 – Chest pain 6. 784 – Symptoms involving head and neck 784.0 - Headache 7. 787 – Symptoms involving digestive system 787.2 - Dysphagia 8. 719 – Other and unspecified disorders of joint 719.46 – Pain in joint, lower leg 9. 272 – Disorders of lipoid metabolism 272.4 – Other and unspecified hyperlipidemia
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10. 724 – Other and unspecified disorders of back 724.5 – Backache, unspecified Top ICD-9 Codes for Subsequent Inpatient Encounters 1. 276 – Disorders of fluid electrolyte and acid-base balance 276.8 - Hypopotassemia 2. 401 – Essential Hypertension 401.9 - Unspecified essential hypertension 3. 250 – Diabetes mellitus 250.0 - Diabetes mellitus without mention of complication 4. 285 – Other and unspecified anemias 285.9 – Anemia, unspecified 5. 305 – Nondependent abuse of drugs 305.1 – Tobacco use disorder 6. 787 – Symptoms involving digestive system 787.2 - Dysphasia 7. 780 – General symptoms 780.39 – Other convulsions 8. 427 – Cardiac dysrhythmias 427.31 – Atrial fibrillation 9. 294 – Persistent mental disorders due to conditions classified elsewhere 294.9 – Unspecified persistent mental disorders due to conditions classified elsewhere 10. 272 – Disorders of lipoid metabolism 272.4 – Other and unspecified hyperlipidemia
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SC 65 (54%) 50 (41%) 6 (5%) 0 (0%) 3 (1-6)
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36 (52%) 32 (46%) 1 (1%) 0 (0%) 3 (2-4)
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Admit Type 1724 (60%) Trauma 995 (35%) Medical Emergency 133 (5%) Urgent 3 (0.1%) Other 2 (1-4) Total Encounters* *Median (interquartile range)
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Table 2: Injury characteristics of participants based on loss of consciousness classification. <1 hr LOC 1-24 hrs LOC >24 hrs LOC Unspecified (N=2855) (n=69) (n=121) (n=1734) 4 (2-8) 21 (7-31) 29 (18-44) 5 (2-12) LOS* Total Charges (in 34.5 (22.2 – 61.8) 166.4 (63.9-268.3) 228.2 (125-345) 37.1 (21.4-84.9) thousands)* 3M Severity 414 (15%) 1 (1%) 0 (0%) 281 (16%) Minor 982 (34%) 9 (13%) 6 (5%) 582 (34%) Moderate 1018 (36%) 14 (20%) 19 (16%) 523 (30%) Major 437 (15%) 45 (65%) 95 (79%) 347 (20%) Extreme 4 (0.1%) 0 (0%) 1 (1%) 1 (0.1%) Ungroupable 702 (40%) 973 (56%) 58 (3%) 1 (0.1%) 2 (1-4)
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Table 4: Injury characteristics of participants based on 3M classification.
TBI Severity Mild (<1 hr LOC) Moderate (1-24 hrs LOC) Severe (24+ hrs LOC) Unspecified Admit Type Trauma Medical Emergency Urgent Other Total Encounters*
Ungroupable (n=6)
2.9±2.9 2 (1-4) 0-26
3.9±3.4 3 (2-5) 0-38
7.9±6.5 6 (4-10) 0-54
24±17 20 (12-32) 1-150
4.8±3.8 5 (2-6) 0-11
23.6±17.3 19.0 (14.0 – 27.8) 2.5-221.0
31.2±28.9 25.8 (19.036.2) 0-861.7
58.7±44.9 45.4 (30.672.0) 1.1-483.1
198.7±142.2 162.4 (93.5268.6) 8.8-1075.6
55.8±27.2 43.9 (35.8-79.0)
414 (59%)
982(62%)
1018 (65%)
437 (47%)
1 (0.1%)
9 (0.6%)
14 (1%)
45 (5%)
4 (67%) 0 (0%)
0 (0%)
6 (0.4%)
19 (1%)
95 (10%)
281 (40%)
582 (37%)
523 (33%)
347 (38%)
1 (17%)
279 (40%) 389 (56%) 27 (4%) 11 (1%) 2 (1-3)
760 (48%) 753 (48%) 64 (4%) 0 (0%) 2 (1-4)
919 (58%) 584 (37%) 70 (4%) 25 (1%) 3 (1-5)
563 (61%) 323 (35%) 37 (4%) 0 (0%) 4 (2-6)
6 (100%) 0 (0%) 0 (0%) 0 (0%) 1 (1-2)
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*Median (interquartile range)
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Extreme (n=924)
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Min-Max
Major (n=1574)
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median (Q1, Q3)
Moderate (n=1579)
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LOS mean±SD median (Q1, Q3) Min-Max Total Charges (in thousands) mean±SD
Minor (N=696)
32.8-99.3
1 (17%)
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Table 5: Superutilizers Superutilizers (N=1021) 56.6±22.3 639 (18%)
Others (N=3758) 49.0±21.5 2450 (82%)
p-value
555 (20%) 228 (29%) 238 (20%) 153 (16%)
2249 (80%) 570 (71%) 939 (80%) 788 (84%)
<0.0001 0.6833 0.9620
221 (14%) 404 (32%) 66 (31%) 330 (19%)
1356 (86%) 855 (67%) 146 (69%) 1401 (81%)
<0.0001 <0.0001 <0.0001
106 (15%) 277 (18%) 361 (23%) 277 (30%) 0 (0%)
590 (85%) 1302 (82%) 1213 (77%) 590 (85%) 6 (100%)
0.8645 0.1870 0.0298 0.9720
2225 (78%) 56 (81%) 85 (70%) 1392 (80%) 4 (2-9)
0.1170 0.8204 0.1326 0.0416
2600 (84%) 511 (72%) 357 (69%) 49 (44%) 241 (68%)
<0.0001 0.0004 <0.0001 <0.0001
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0.0291 <.0001
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Demographics Age Male Gender Race White Black Other Hispanic Ethnicity Insurance Private Medicare Medicaid Uninsured 3M Severity Score Minor Moderate Major Extreme Ungroupable TBI Severity Mild (<1 hr LOC) Moderate (1-24 hrs LOC) Severe (24+ hrs LOC) Unspecified Length of Stay Discharge Location Home Rehabilitation Skilled Nursing Facility Longterm Acute Care Other
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479 (16%) 203 (28%) 160 (31%) 63 (56%) 116 (32%)
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Table 1. Demographic and injury related characteristics of sample at index hospitalization. N=4779
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1577 (33%) 1259 (26%) 212 (4%) 1731 (36%)
9±11.5 5 (2,10) 0-150
71.6±94.6 36.1 (22.4, 73.9) 0-1075.6
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2804 (59%) 798 (17%) 84 (2%) 1076 (23%) 941 (20%)
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50.6±21.9 3089 (65%)
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Demographics Age Male Gender Race White Black Asian Other Hispanic Ethnicity Insurance Private Medicare Medicaid Uninsured Clinical (initial trauma) LOS mean±SD median (Q1, Q3) Min-Max Total Charges (in thousands) mean±SD median (Q1, Q3) Min-Max 3M Severity Score Minor Moderate Major Extreme Ungroupable TBI Severity Mild (<1 hr LOC) Moderate (1-24 hrs LOC) Severe (24+ hrs LOC) Unspecified Admit Type Medical Emergency Trauma Urgent Other Specialization
696 (15%) 1579 (33%) 1574 (33%) 924 (19%) 6 (0.1%) 2855 (60%) 69 (1%) 121 (3%) 1734 (36%) 2050 (43%) 2527 (53%) 198 (4%) 4 (<1%)
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4233 (89%) 269 (5%) 277 (6%)
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Trauma Surgery Other (Combined specializations listed for ≤1% of the patients) Not Listed
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Figure 1: Healthcare utilization between January 2006 and June 2014
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16,717 patients admitted to the trauma center 1/1/06-6/30/14 N=5,291 patients with TBI
n=512 expired during index admission
12,307 encounters
n=1,621 with no identified additional healthcare utilization captured in this database
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n=3,158 patients with additional healthcare encounters in DFW
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n=4,779 surviving patients with TBI
9,769 non-admission urgent
or procedural visits
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2538 inpatient encounters
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Figure 2: Healthcare encounters within one year of injury
Twenty-two individuals did not have any documented services in the database during the first year after injury yet had subsequent services.
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S0003-9993(16)31140-6
DOI:
10.1016/j.apmr.2016.09.117
Reference:
YAPMR 56689
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 23 March 2016 Revised Date:
29 August 2016
Accepted Date: 11 September 2016
Please cite this article as: Salisbury D, Driver SJ, Reynolds M, Bennett M, Petrey LB, Warren AM, Hospital-based health care after traumatic brain injury, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.09.117. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Running head: HEALTH CARE AND TBI Title: Hospital-based health care after traumatic brain injury
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Authors: David Salisbury, Psy.D.1, Simon J. Driver, Ph.D1, Megan Reynolds, M.S. 1,Monica
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Bennett, Ph.D.2., Laura B. Petrey, M.D2., and Anne Marie Warren, Ph.D2. Affiliated institutions: 1Baylor Institute for Rehabilitation, Dallas;
Baylor Scott & White,
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Dallas.
2
Acknowledgement of presentation of material: Some of the data from this paper were presented at the American Congress of Rehabilitation Medicine Meeting in Dallas (2015). Acknowledgement of financial support: The project was supported by the Ginger Murchison
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Foundation Traumatic Brain Injury Research Fund. The contents of this manuscript were also developed under a grant from the National Institute on Disability, Independent Living, and
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Rehabilitation Research (NIDILRR grant number 90DP0045-01-0). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services
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(HHS). The contents of this manuscript do not necessarily represent the policy of NIDILRR, ACL, HHS, and you should not assume endorsement by the Federal Government. Conflict of Interest: No conflicts were endorsed by the authors. Correspondence concerning this article should be addressed to David B. Salisbury, Department of Neuropsychology, Baylor Institute for Rehabilitation, 411 N. Washington Ave., Suite 5000, Dallas, Texas, 75246. Phone: 214.820.7964. E-mail: [email protected]
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Hospital-based Health Care after Traumatic Brain Injury
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Abstract
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Objective: To investigate trends of hospital-based health care utilization after admission to a
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Level 1 trauma center following acute traumatic brain injury (TBI).
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Design: Retrospective review.
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Setting: Large urban trauma hospital and a hospital council data registry consisting of 88
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member institutions (>150 hospitals) covering 15,000 square miles.
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Participants: All patients admitted to a Level I trauma center between January 2006 - June 2014
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who experienced an acute TBI based on ICD-9 coding.
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Intervention: Not applicable.
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Main Outcome Measures: Included the incidence and type of select hospital-based services
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received. Analyses were also categorized based on demographic and injury-related information.
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Results: There were 5,291 patients with newly acquired TBI admitted; 512 died, leaving 4,779
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patients for inclusion into the final analysis. Additional healthcare utilization from January 2006-
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June 2014 was recorded for 3,158 patients (66%), totaling 12,307 encounters with a median of 3
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encounters (IQR: 1-5), and a maximum of 102 encounters. The vast majority of non-admission
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urgent or procedural visits (96%) and inpatient encounters (93%) occurred in the first year. Of all
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the additional encounters, 9,769 visits were non-admission urgent or procedural visits (79%)
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with a median charge of $1,955, and most common type of encounter being elective (46%),
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followed by medical emergency (29%). Of the remaining 2,538 (21%) inpatient encounters, the
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mean length of stay was 6 days with median charge of $28,450, and medical emergency (39%)
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and elective admissions (33%) again being the most common encounter type.
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Conclusions: This analysis encompasses healthcare utilization across the range of TBI severity
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and numerous hospital systems allowing for a more comprehensive and objective identification
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of reasons for readmission. This represents an initial step to developing a preventative
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intervention to manage secondary complications post-injury.
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Key Words: TBI, readmissions, outcomes
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In the ever-changing culture of healthcare, an emphasis upon identification and tracking of
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potentially preventable and often costly medical complications has garnered significant interest.
36
This focus will only intensify as hospitals are mandated to make readmission rates publically
37
available for various medical conditions and financial penalties are mandated for specific types
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of readmission by common payer sources such as Medicare and Medicaid 1,2. The increasing use
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and ultimate integration of large electronic medical record databases will likely play a
40
determining role in shaping policy and practice related to preventative and primary healthcare
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practices.
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The application of comprehensive and longitudinal databases would be beneficial for neurorehabilitation populations such as traumatic brain injury (TBI) where follow-up care may
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occur across the lifespan. In fact, conceptualizing moderate to severe TBI as a chronic condition
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has been advocated by some groups 3,4. This potential paradigm shift is based on the support for
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longstanding risks of increased morbidity (e.g., diabetes, hypertension), mortality, as well as the
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chronic cognitive and psychological sequelae that can accompany some survivors of TBI 4,5.
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Hence, the impact of moderate to severe TBI can be seen as an evolving process that has
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pervasive effects on the survivor, family, community, and society as a whole 3,6. This revised
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outlook upon moderate to severe TBI would align with the need to adopt a chronic care model of
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treatment which has been shown to be effective across various medical conditions 7,8.
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The impetus to improve management of TBI becomes even more pressing when
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considering the global estimates of up to 10 million individuals impacted yearly9,10. Trends
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within the United States (U.S.) show TBI to be a primary or secondary diagnosis in 2-3.5 million
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yearly emergency department visits, hospitalizations and deaths 11,12. The vast majority of
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individuals diagnosed with TBI sustain a mild TBI/concussion 11,13-15. Within the subgroup of 4
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people with mild TBI without additional complications, there is a good prognosis for rapid
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recovery to prior functioning and increased use of health-care services would not be expected 16-
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18
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problems and can be at risk for future health care services. For those with complicated recoveries
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extending beyond three months, numerous secondary factors such as litigation, substance abuse,
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medical and psychiatric history have been suggested to play a role 18-22
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. Controversy remains about the clear minority of mild TBI patients who report persistent
The increased TBI-related emergency room visits and decline in TBI-related deaths (e.g. 19.9 per 100,000 in 1995 to 16.6 per 100,000 in 2009) foreshadow a greater societal burden to
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provide appropriate treatment in the decades to come12. Prior studies have suggested
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rehospitalization rates from 20-28% in the first year after moderate to severe traumatic brain
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injury with initial readmissions often being elective (e.g., orthopedic, reconstructive procedures),
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while utilization across-time has been linked to medical comorbidites, infection, seizures and
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behavioral/psychiatric reasons 23-30. Ma et al (2014) 31summarized TBI studies in the U.S.
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focused on societal impact to conclude that direct costs may reach $13.1 billion and indirect cost
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could exceed 64 billion.
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However, there are many barriers to better understanding the complications of TBI
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including a lack of integrated health records, limited generalizability of studies focused on
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specific subgroup of TBI survivors, reliance upon self-report of post-TBI complications, and
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challenges of interpreting studies based on differing health care systems 28,32. This study attempts
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to address limitations of previous studies that have used selective and non-generalizable patient
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samples by combining trauma and regional registry datasets from a large metropolitan area. The
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primary aim is to clarify the frequency and characterize the nature of health care utilization
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across the continuum of TBI severity with a very diverse sample. A secondary aim is the
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identification of individuals at risk for high health care utilization after the initial TBI as this
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target group may be ideal for preventative interventions.
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Methods
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Procedure
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Following approval from the institutional review board, a single Level 1 trauma Center registry
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was combined with the Dallas-Fort Worth Hospital Council Foundation (DFWHCF) utilization
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data from January 2006-June 2014 and. Specifically, this retrospective cross-sectional design
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involved patients who experienced a TBI during their index as determined by Codes from the
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International Classification of Disease – 9th Edition (ICD-9) (i.e., 800-804 with .0 and .5
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excluded, and 850-854).
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The large trauma center in the Southwest United States admits approximately 2,500 patients annually, including 650-700 individuals with TBI. The combined database allowed us to
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track the frequency and nature of healthcare utilization across time. The DFWHCF collects data
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from 88 member institutions (>150 hospitals), including more than 96% of all hospital
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discharges across 15,000 square miles of North Texas. Institutions submitting data to the
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DFWHCF include three Level I trauma centers, three level II centers, and five Level III centers.
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Data from the DFWHCF includes hospital admissions and non-admission emergent or
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procedural visits. More specifically this data captures a variety of services such as ambulatory
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surgery, emergency department visits, observation, radiology and cardiac catherization.
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Outpatient laboratory visits and hospital-based outpatient clinic visits are not included in the
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database. This data is collapsed into broader categorizations, based on state reporting 6
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requirements, primarily linked to the physician specialty or procedure, thus specific analysis on
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multidisciplinary services provided was not available. Skilled nursing facilities (SNFs) and
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long-term acute care hospitals (LTACs) were not included in this analysis as few facilities have
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historically contributed data to the DFWHCF, limiting any meaningful analysis.
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Data
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Variables queried from the trauma registry and DFWHCF included (1) demographic information
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(e.g., age, gender, race, ethnicity, insurance type), (2) duration of loss of consciousness (<1 hour;
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1-24 hours; and >24 hours) , (3) healthcare utilization data (e.g., diagnosis codes, inpatient
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procedures, dates of admission and discharge, discharge disposition, date(s) of utilization,
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primary and secondary diagnoses, and principal procedures) and (4) 3M™ All Patient Refined
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Diagnosis Related Group (APR DRGs) used by DFWHCF to measure burden of illness (for
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additional information about the development and validity of this tool please see
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http:www.#Mhis.com and the white paper referenced) 33. The 3M™ variable classifies severity
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of index admissions based on diagnoses and procedure performed with subclasses including:
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minor, moderate, major and extreme. These numerical values do not represent scores but a
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continuum based on algorithms that account for the interaction between factors such as age,
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gender, chronic condition(s) severity, co-morbidities, nature and likely duration of
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complications, potential resource utilization and mortality risk. The DRGs have been validated
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with national data and were implemented in the 1990s. Individuals in the higher severity
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classifications typically have a worse prognosis due to the presence of multiple conditions
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impacting numerous organ systems. This system is analogous to the Centers for Medicare and
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Medicaid Severity Diagnosis Related Groups and used by numerous health plans, state agencies,
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accountable care organizations and providers.
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Statistical Analysis
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All data were summarized using standard descriptive statistics. Mean and standard deviation or
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median and interquartile range were used for quantitative variables, and counts and percentages
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were used for all qualitative variables. In an effort to identify superutilizers of health care after
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the initial TBI, we focused upon the subgroup of the sample at the 75th percentile for both
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inpatient and non-admission urgent or procedural visits coded as medical emergency, urgent, or
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trauma related. Two such encounters fell at the 75th percentile. Patients who had three or more
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encounters in year following index admission were labeled as superutilizers. Multiple logistic
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regression was used to determine which factors were associated with being in the super-utilizer
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group.
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Results
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Subjects and Index Admission Characteristics
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Between January 1, 2006 and June 30, 2014, 16,717 individuals were admitted to the institution
139
with a traumatic injury (Figure 1). We identified 5,291patients age 18 and older with index
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trauma admissions of TBI. Of these, 512 patients died during their index admission and were
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excluded from analysis, accounting for a final total of 4,779 patients with TBI.
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Demographic and clinical information for the original trauma admission is presented in
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Table 1. Mean age of the final sample of TBI patients (N=4,779) was 50.6 (±21.9), with the
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majority male (65%) and Caucasian (59%), which is consistent with the overall injured patient
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population at the trauma center. At index admission, 67% of patients did not have private
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insurance. Median length of stay (LOS) for index admissions was 5 days, accounting for a
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median cost of $36,100 in charges. The only acute indicator of TBI severity that was captured consistently enough to be
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meaningfully interpreted was loss of consciousness. Of those who could be classified, the
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majority (60%) were documented as having less than one hour loss of consciousness. As
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expected, the median LOS dramatically jumped when loss of consciousness increased from less
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than one hour (LOS = 4 days) to 1-24 hours (LOS = 21 days) or greater than 24 hours (LOS = 29
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days) (Table 2).
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The ten most frequent ICD-9 codes documented for initial hospitalization are presented in Table 3. The broad 3M™ DRG categorization demonstrated that median LOS and hospital
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charges consistently increased across the severity categories (Table 4). Among the sample, 85%
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of individuals’ severity of index admission was rated as moderate to extreme.
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Characteristics of Additional Healthcare Utilization
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Of the 4,779 TBI patients included in the sample, 66% (n=3,158) had additional healthcare
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utilization beyond their index admission, accounting for 12,307 total additional patient
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encounters (Figure 1). The length of time followed post-discharge from acute hospitalization
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varied given the initial injury date for patients with a range of 0-8.5 years, mean of 4.2 (+2.4
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years) and median (Q,1 Q3) of 4.2 years (2.2, 6.2). Of the total additional patient encounters,
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79% (n= 9,769) were non-admission urgent or procedural visits and 21% were inpatient
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(n=2538). The median number of additional visits was 3 (IQR: 1-5), with a maximum number of
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102 additional encounters. There was also a decrease in the frequency of admissions over time
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(Figure 2). In the first year post-injury most non-admission urgent or procedural visits (96%) and
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inpatient encounters (93%) occurred. By the second year, non-admission urgent or procedural
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visits (2.0%) and inpatient encounters (3.4%) dramatically decreased with a further trend of
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decline in subsequent years.
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The median charge for a non-admission urgent or procedural visit was $1,955. Of these visits, 46% were elective in nature, while 29% were listed as medical emergencies or urgent. The
174
overall median charge was greatly impacted by those cases involving associated procedural
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codes (e.g. injections, surgery), most often seen among visits classified as medical emergencies
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or urgent. For these cases, the median charge was $4,540. Among non-admission urgent or
177
procedural visits, the top specializations involved included emergency medicine (20%),
178
specialists (9%), and physical medicine and rehabilitation (8%), neurological surgery and
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internal medicine (7% each). The most common ICD-9 codes documented were essential
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hypertension (18%), nondependent abuse of drugs (14%) with the majority being tobacco
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related, and diabetes mellitus (9%) (Table 3).
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encounters were often medical emergencies (39%), elective (33%) or urgent (24%). The top
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specializations involved included internal medicine (30%), trauma surgery (8%), hospitalists
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(7%) and physical medicine and rehabilitation (6%). Among this subsample, the most frequently
186
documented ICD-9 codes were disorders of fluid electrolytes and acid-base balance (50%),
187
essential hypertension (46%), diabetes mellitus (30%) and unspecified anemia (29%).
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Nondependent abuse of drugs (27%), primarily related to tobacco use, and persistent mental
189
disorders due to conditions classified elsewhere (23%) were also common reasons for utilization
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(Table 3).
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Patients who had three or more encounters in year following index admission (N = 1021) were labeled as superutilizers. Demographic information for TBI patients stratified by
193
superutilizers is presented in Table 5. A review of demographics indicated that a significantly
194
greater number of females (p<.0001), African Americans (p<.0001), and individuals without
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private insurance (p<.0001) were in the superutilization group. While no difference in utilization
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was found based on loss of consciousness, a significantly greater number of individuals
197
classified as extreme (p=0.0298) based on the 3MTM severity score were superutilizers.
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Superutilizers were significantly less likely to be discharged home (47% vs. 69%) and
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significantly more likely to transition to rehabilitation care (20% vs. 14%; p<.0001), LTAC
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facilities (6% vs. 1%; p<.0001) or SNF (16% vs. 10%; p = .004).
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superutilizers were 2.1 times greater ($97,781,753 vs. $46,691,604) than the total charges of all
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other patients. This charge differential may be explained by the increased length of stay and
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greater medical complexity (per the 3M™ DRG categorization) among the superutilization
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group. The primary diagnosis and distribution for inpatient readmissions and non-admission
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urgent or procedural visits for the superutilizers was surprisingly similar to that of the general
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sample.
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Discussion
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Findings from this regional database represent a platform to better understand care utilization
209
after TBI. The preponderance of medical care utilized within the first year after injury has been
210
detailed in prior samples, but the surprisingly low rate of care utilization after the first year is
211
well below that of prior studies 23,28,29. Most likely, the inclusion of all TBI severity levels
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resulted in a larger portion of milder injuries. Mild TBI is not expected to be linked to increased
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future medical encounters after discharge unless there are additional medical complications.
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The total charges for high
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Approximately half of our probable mild TBI patients had lower global injury severity rating
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based on 3M™ DRG categorization. Hence, this subgroup unlikely had significant medical
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complications that would necessitate extensive future care. Considering the higher percentage of
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minority patients in our sample as compared to prior studies 25,34,35, this database may lend itself
218
to better understanding previously raised concerns in the literature regarding post-injury
219
outcome after moderate-severe traumatic brain injury. Level of care in the emergency room,
220
access to inpatient rehabilitation and specialized outpatient care has been discrepant for some
221
minority populations impacting outcome even when accounting for demographic and severity of
222
injury 36-40. It will be important to rule out access to primary and specialized care when further
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considering care utilization trends. Given the ability to capture rehospitalizations over a large
224
catchment area outside of the admission hospital system, it is unlikely that the low rates of care
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utilization solely reflect missed contacts seen in other systems.
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categorization of primary services sought and ICD-9 codes. Similarities were noted across
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inpatient and non-admission urgent or procedural visits. However, inpatient encounters were
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more often related to medical emergencies with a relatively comparable percentile of elective
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admissions whereas elective admissions dominated non-admission urgent or procedural visits.
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The most prevalent ICD-9 codes recorded after index admission were notable for potentially
232
treatable comorbidities (e.g. disorders of fluid electrolytes, diabetes mellitus, and hypertension).
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This promising finding further supports the possibility of enhanced discharge planning and
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preventative care strategies to decrease medical care needs after TBI.
235 236
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Further analysis of a subgroup of superutilizers focused on encounters only in the year after injury. Given the dramatic decline in health care accessed after the first year, this first year 12
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time frame likely captures the window of opportunity for preventative interventions and better
238
management of health care costs. Superutilizers accounted for over twice the charges of the
239
whole sample, while consisting of only 21% of the study population. As expected, general injury
240
severity was higher in this subgroup which required longer stays and were less likely discharged
241
home after the index injury. However, the reason for future inpatient and non-admission urgent
242
or procedural visits in this group mirrored the larger sample. Furthermore, a comparison of
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patient specific variables yielded only a few primary differences with regards to ethnicity and
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insurance type. Still, this subgroup remains a priority for further research. Additional variables
245
such as appropriate post-discharge follow-up and preventative care along with patient health
246
literacy are not available in the broader database and could fuel the care need discrepancy with
247
this subgroup.
248
Study Limitations
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Limitations in the current analysis are readily acknowledged. Specifically, these results include
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patients with TBI originally admitted to a single trauma center and do not reflect a population-
251
based sample. Similarly, this data is composed of administrative data collected from both trauma
252
and non-trauma centers, which may affect how data was abstracted. In addition, it is nearly
253
impossible to determine if the 34% of individuals without healthcare utilization post-TBI
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remained within the region served by DFWHCF and did not require utilization, or if the
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individuals relocated to outside of the region or expired. Nevertheless, the information provided
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by the DFWHCF represents a vast improvement over data reliant upon a single healthcare
257
facility/system, subgroup of patients with TBI, or self-reported data.
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The database variables to clarify traumatic brain severity information were also limited. As previously mentioned, the database used duration of loss of consciousness (<1 hour; 1-24
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hours, 24+ hours) that differed from typical clinical categorizations that often identify the mildest
261
injuries as involving loss of consciousness below thirty minutes. This prohibits a more traditional
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demarcation of mild, moderate and severe TBI categorization based on loss of consciousness. Of
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those who could be classified, the majority (60%) were documented as having less than one hour
264
LOC. Thirty-six percent of patients were grouped as unspecified TBI severity given the lack of
265
loss of consciousness information that could be obtained. When comparing the group with
266
unspecified duration loss of consciousness to all others, the unspecified group was very similar
267
to the less than one hour loss of consciousness group in regards to LOS, typical hospital charges
268
and general severity data. This would suggest that the unspecified category primarily included
269
individuals who sustained the mildest level of TBI.
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When reviewing the patient discharge information, superutilizers are found to be more
271
commonly discharged to LTAC or SNF facilities. Of note though, the database does not clarify
272
the number of patients admitting from a LTAC or SNF initially.
273
particularly age, similarities between the superutilizer group and the larger sample would not
274
suggest that premorbid residence for this group was more likely in a SNF or a LTAC facility but
275
this will require further analyses outside the scope of this dataset.
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Finally, the inability to capture hospital-based outpatient clinic visits within the larger
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database must be reiterated. This likely underestimated the subsequent care received after TBI in
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our sample. The decision to omit SNF and LTAC settings was again primarily based on the
279
limited number of facilities that contribute to the database. A future focus on this subgroup may
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be possible as a current project is under way to create a separate database to capture health care
281
utilization in SNF and LTAC.
282
Conclusions
283
The ultimate goal of preventative interventions to better manage TBI and minimize future health
284
complications requires a clearer understanding of frequent complications post injury. This study
285
represents an initial analysis of trends using a regional database that allows for tracking of health
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care utilization following TBI across healthcare systems. The data suggests that potentially
287
treatable comorbidities such as electrolyte imbalance, diabetes mellitus, and hypertension could
288
be prime targets for patient or family interventions after TBI.
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References
rates of readmissions. N Engl J Med. 2009;361(27):2637-2645. 2. Vest JR, Gamm LD, Oxford BA, Gonzalez MI, Slawson KM.
RI PT
1. Jha AK, Orav EJ, Epstein AM. Public reporting of discharge planning and
Determinants of preventable readmissions in the united states: A systematic
SC
review. Implement Sci. 2010;5:88-88.
3. Corrigan J, D., Hammond F, M. Traumatic brain injury as a chronic health
M AN U
condition. Arch Phys Med Rehabil. 2013;94(6):1199-1201.
4. Masel BE, DeWitt DS. Traumatic brain injury disease: Long-term consequences of traumatic brain injury. In: Levin HS, Shum DHK, Chan RCK, Levin HS(, Shum DHK(, Chan RCK(, eds. New York, NY, US:
TE D
Oxford University Press; 2014:28-53.
http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=201440048-003&site=eds-live&group=test.
EP
5. Chauhan NB. Chronic neurodegenerative consequences of traumatic brain injury. Restor Neurol Neurosci. 2014;32(2):337-365.
AC C
6. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury. J Head Trauma Rehabil. 2006;21(5):375-378. 7. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2-4. 8. Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Effectiveness of chronic care models: Opportunities for improving healthcare practice and
16
ACCEPTED MANUSCRIPT Running head: HEALTH CARE AFTER TBI
health outcomes: A systematic review. BMC Health Services Research. 2015;15(1):1-11. 9. Humphreys I(1), Phillips CJ(1), Wood RL(2), Macey S(3). The costs of
Research. 2013;5(1):281-287.
RI PT
traumatic brain injury: A literature review. ClinicoEconomics and Outcomes
10. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye
NeuroRehabilitation. 2007;22(5):341-353.
SC
OC. The impact of traumatic brain injuries: A global perspective.
M AN U
11. Centers for Disease Control and Prevention (CDC). Report to Congresstraumatic brain injury in the united states: epidemiology and rehabilitation .
TBI_Report_to_Congress_Epi_and_Rehab Web site.
TE D
http://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_ and_Rehab-a.pdf. Accessed August 24, 2015.
12. Coronado VG, McGuire LC, Sarmiento K, et al. Trends in traumatic
EP
brain injury in the U.S. and the public health response: 1995–2009. J Saf Res. 2012;43(4):299-307.
AC C
13. Coronado V, G., Haileyesus T, Cheng T, A., et al. Trends in sports- and recreation- related traumatic brain injuries treated in US emergency departments: The national electronic injury surveillance system-all injury program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil. 2015;30(3):185197. 14. Marin JR, Weaver MD, Yealy DM, Mannix RC. Trends in visits for
17
ACCEPTED MANUSCRIPT Running head: HEALTH CARE AFTER TBI
traumatic brain injury to emergency departments in the United States. JAMA. 2014;311(18):1917-1919. 15. Rutland-Brown W, Langlois JA, Thomas KE, Xi YL. Incidence of
RI PT
traumatic brain injury in the United States, 2003. J Head Trauma Rehabil. 2006;21(6):544-548.
16. Babikian T, Asarnow R. Neurocognitive outcomes and recovery after
SC
pediatric TBI: Meta-analytic review of the literature. Neuropsychology. 2009;23(3):283-296.
M AN U
17. Nelson LD, Janecek JK, McCrea MA. Acute clinical recovery from sportrelated concussion. Neuropsychol Rev. 2013;23(4):285-299.
18. Rohling ML, Binder LM, Demakis GJ, Larrabee GJ, Ploetz DM, Langhinrichsen-Rohling J. A meta-analysis of neuropsychological outcome
TE D
after mild traumatic brain injury: Re-analyses and reconsiderations of Binder et al. (1997), Frencham et al. (2005), and Pertab et al. (2009). Clin Neuropsychol. 2011;25(4):608-623.
EP
19. Belanger HG, Curtiss G, Demery JA, Lebowitz BK, Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic
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brain injury: A meta-analysis. J Int Neuropsychol Soc. 2005;11(3):215-227. 20. Karr JE, Areshenkoff CN, Garcia-Barrera M. The neuropsychological outcomes of concussion: A systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. Neuropsychology. 2014;28(3):321-336. 21. King NS. A systematic review of age and gender factors in prolonged
18
ACCEPTED MANUSCRIPT Running head: HEALTH CARE AFTER TBI
post-concussion symptoms after mild head injury. Brain Injury. 2014;28(13):1639-1645. 22. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A,
traumatic brain injury. Neuropsychology. 2012;26(3):304-313.
RI PT
Schönberger M. Predictors of postconcussive symptoms 3 months after mild
23. Cifu DX, Kreutzer JS, Marwitz JH, et al. Etiology and incidence of
SC
rehospitalization after traumatic brain injury: A multicenter analysis. Arch Phys Med Rehabil. 1999;80(1):85-90.
M AN U
24. Corrigan JD, Horn SD, Barrett RS, et al. Effects of patient preinjury and injury characteristics on acute rehabilitation outcomes for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8, Supplement):S209-S221.e6. 25. Hammond FM, Horn SD, Smout RJ, et al. Rehospitalization during 9
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months after inpatient rehabilitation for traumatic brain injury. Arch Phys Med Rehabil. 2015;96(8, Supplement):S330-S339.e4. 26. Kayani NA, Homan S, Yun S, Zhu BP. Health and economic burden of
EP
traumatic brain injury: Missouri, 2001-2005. Public Health Rep. 2009;124(4):551-560.
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27. Leibson CL, Brown AW, Hall Long K, et al. Medical care costs associated with traumatic brain injury over the full spectrum of disease: A controlled population-based study. J Neurotrauma. 2012;29(11):2038-2049. 28. Marwitz JH, Cifu DX, Englander J, High WM, J. A multi-center analysis of rehospitalizations five years after brain injury. J Head Trauma Rehabil. 2001;16(4):307-317.
19
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29. Prang K, Ruseckaite R, Collie A. Healthcare and disability service utilization in the 5-year period following transport-related traumatic brain injury. Brain Inj. 2012;26(13-14):1611-1620.
RI PT
30. Tuominen R, Joelsson P, Tenovuo O. Treatment costs and productivity losses caused by traumatic brain injuries. Brain Injury. 2012;26(13):16971701.
SC
31. Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the united
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states: Stroke, spinal cord injury, traumatic brain injury, multiple sclerosis,
osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil. 2014;95(5):986-995.e1.
32. Stroupe K, T., Smith B, M., Hogan T, P., et al. Healthcare utilization and
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costs of veterans screened and assessed for traumatic brain injury. J Rehabil Res Dev. 2013;50(8):1047-1068.
33. Averill RF, Goldfield NI, Eisenhandler J. et al. development and
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evaluation of the clinical risk groups (CRGS).. 1999(Final Report to the National Institutes of Standards and Technology, US Department of
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Commerce).
34. Corrigan JD, Selassie AW, Lineberry LA, et al. Comparison of the traumatic brain injury (TBI) model systems national dataset to a populationbased cohort of TBI hospitalizations. Arch Phys Med Rehabil. 2007;88(4):418-426. 35. Cuthbert JP, Corrigan JD, Whiteneck GG, et al. Extension of the
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representativeness of the traumatic brain injury model systems national database: 2001 to 2010. J Head Trauma Rehabil. 2012;27(6):E15-E27. 36. Bowman SM, Martin DP, Sharar SR, Zimmerman FJ. Racial disparities
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in outcomes of persons with moderate to severe traumatic brain injury. Med Care. 2007;45(7):686-690.
37. Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences
literature. Brain Inj. 2009;23(10):775-789.
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exist in post-injury outcomes after TBI? A comprehensive review of the
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38. Kane WG, Wright DA, Fu R, Carlson KF. Racial/ethnic and insurance status disparities in discharge to posthospitalization care for patients with traumatic brain injury. J Head Trauma Rehabil. 2014;29(6):E10-7.
39. Shafi S, Marquez de la Plata C, Diaz-Arrastia R, et al. Racial disparities
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in long-term functional outcome after traumatic brain injury. J Trauma. 2007;63(6):1263-8; discussion 1268-70.
40. Shafi S, de lP, Diaz-Arrastia R, et al. Ethnic disparities exist in trauma
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care. J Trauma. 2007;63(5):1138-1142. 289
Figure Legend
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Figure 1: Healthcare utilization between January 2006 and June 2014
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Figure 2: Healthcare encounters within one year of injury
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Table 3. Top ICD-9 codes for hospitalization among TBI patients
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Top ICD-9 Codes for Initial Hospitalization 1. 276 – Disorders of fluid electrolyte and acid-base balance 276.8 - Hypopotassemia 2. 305 – Nondependent abuse of drugs 305.1 – Tobacco use disorder 3. 852 – Subarachnoid subdural and extradural hemorrhage following injury 852.2 – Subdural hemorrhage following injury w/o mention of open intracranial wound 4. 802 – Fracture of face bones 802.0 – Closed fracture of nasal bones 5. 401 – Essential hypertension 401.9 – Unspecified essential hypertension 6. 873 – Other open wound of head 873.0 – Open wound of scalp, w/o mention of complication 7. 805 – Fracture of vertebral column without mention of spinal cord injury 805.4 – Closed fracture of lumbar vertebra without mention of spinal cord injury 8. 801 – Fracture of base of skull 801.26 – Closed fracture of base of skull w/ subarachnoid, subdural, extradural hemorrhage 9. 518 – Other diseases of lung 518.81 – Acute respiratory failure 10. 285 – Other and unspecified anemias 285.1 – Acute posthemorrhagic anemia Top ICD-9 Codes for non-admission urgent or procedural visits 1. 401 – Essential hypertension 401.9 – Unspecified essential hypertension 2. 305 – Nondependent abuse of drugs 305.1 – Tobacco use disorder 3. 780 – General symptoms 780.39 – Other convulsions 4. 250 – Diabetes mellitus 250.0 – Diabetes mellitus without mention of complication 5. 786 – Symptoms involving respiratory system and other chest symptoms 786.5 – Chest pain 6. 784 – Symptoms involving head and neck 784.0 - Headache 7. 787 – Symptoms involving digestive system 787.2 - Dysphagia 8. 719 – Other and unspecified disorders of joint 719.46 – Pain in joint, lower leg 9. 272 – Disorders of lipoid metabolism 272.4 – Other and unspecified hyperlipidemia
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10. 724 – Other and unspecified disorders of back 724.5 – Backache, unspecified Top ICD-9 Codes for Subsequent Inpatient Encounters 1. 276 – Disorders of fluid electrolyte and acid-base balance 276.8 - Hypopotassemia 2. 401 – Essential Hypertension 401.9 - Unspecified essential hypertension 3. 250 – Diabetes mellitus 250.0 - Diabetes mellitus without mention of complication 4. 285 – Other and unspecified anemias 285.9 – Anemia, unspecified 5. 305 – Nondependent abuse of drugs 305.1 – Tobacco use disorder 6. 787 – Symptoms involving digestive system 787.2 - Dysphasia 7. 780 – General symptoms 780.39 – Other convulsions 8. 427 – Cardiac dysrhythmias 427.31 – Atrial fibrillation 9. 294 – Persistent mental disorders due to conditions classified elsewhere 294.9 – Unspecified persistent mental disorders due to conditions classified elsewhere 10. 272 – Disorders of lipoid metabolism 272.4 – Other and unspecified hyperlipidemia
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SC 65 (54%) 50 (41%) 6 (5%) 0 (0%) 3 (1-6)
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36 (52%) 32 (46%) 1 (1%) 0 (0%) 3 (2-4)
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Admit Type 1724 (60%) Trauma 995 (35%) Medical Emergency 133 (5%) Urgent 3 (0.1%) Other 2 (1-4) Total Encounters* *Median (interquartile range)
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Table 2: Injury characteristics of participants based on loss of consciousness classification. <1 hr LOC 1-24 hrs LOC >24 hrs LOC Unspecified (N=2855) (n=69) (n=121) (n=1734) 4 (2-8) 21 (7-31) 29 (18-44) 5 (2-12) LOS* Total Charges (in 34.5 (22.2 – 61.8) 166.4 (63.9-268.3) 228.2 (125-345) 37.1 (21.4-84.9) thousands)* 3M Severity 414 (15%) 1 (1%) 0 (0%) 281 (16%) Minor 982 (34%) 9 (13%) 6 (5%) 582 (34%) Moderate 1018 (36%) 14 (20%) 19 (16%) 523 (30%) Major 437 (15%) 45 (65%) 95 (79%) 347 (20%) Extreme 4 (0.1%) 0 (0%) 1 (1%) 1 (0.1%) Ungroupable 702 (40%) 973 (56%) 58 (3%) 1 (0.1%) 2 (1-4)
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Table 4: Injury characteristics of participants based on 3M classification.
TBI Severity Mild (<1 hr LOC) Moderate (1-24 hrs LOC) Severe (24+ hrs LOC) Unspecified Admit Type Trauma Medical Emergency Urgent Other Total Encounters*
Ungroupable (n=6)
2.9±2.9 2 (1-4) 0-26
3.9±3.4 3 (2-5) 0-38
7.9±6.5 6 (4-10) 0-54
24±17 20 (12-32) 1-150
4.8±3.8 5 (2-6) 0-11
23.6±17.3 19.0 (14.0 – 27.8) 2.5-221.0
31.2±28.9 25.8 (19.036.2) 0-861.7
58.7±44.9 45.4 (30.672.0) 1.1-483.1
198.7±142.2 162.4 (93.5268.6) 8.8-1075.6
55.8±27.2 43.9 (35.8-79.0)
414 (59%)
982(62%)
1018 (65%)
437 (47%)
1 (0.1%)
9 (0.6%)
14 (1%)
45 (5%)
4 (67%) 0 (0%)
0 (0%)
6 (0.4%)
19 (1%)
95 (10%)
281 (40%)
582 (37%)
523 (33%)
347 (38%)
1 (17%)
279 (40%) 389 (56%) 27 (4%) 11 (1%) 2 (1-3)
760 (48%) 753 (48%) 64 (4%) 0 (0%) 2 (1-4)
919 (58%) 584 (37%) 70 (4%) 25 (1%) 3 (1-5)
563 (61%) 323 (35%) 37 (4%) 0 (0%) 4 (2-6)
6 (100%) 0 (0%) 0 (0%) 0 (0%) 1 (1-2)
AC C
EP
*Median (interquartile range)
RI PT
Extreme (n=924)
SC
Min-Max
Major (n=1574)
M AN U
median (Q1, Q3)
Moderate (n=1579)
TE D
LOS mean±SD median (Q1, Q3) Min-Max Total Charges (in thousands) mean±SD
Minor (N=696)
32.8-99.3
1 (17%)
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Table 5: Superutilizers Superutilizers (N=1021) 56.6±22.3 639 (18%)
Others (N=3758) 49.0±21.5 2450 (82%)
p-value
555 (20%) 228 (29%) 238 (20%) 153 (16%)
2249 (80%) 570 (71%) 939 (80%) 788 (84%)
<0.0001 0.6833 0.9620
221 (14%) 404 (32%) 66 (31%) 330 (19%)
1356 (86%) 855 (67%) 146 (69%) 1401 (81%)
<0.0001 <0.0001 <0.0001
106 (15%) 277 (18%) 361 (23%) 277 (30%) 0 (0%)
590 (85%) 1302 (82%) 1213 (77%) 590 (85%) 6 (100%)
0.8645 0.1870 0.0298 0.9720
2225 (78%) 56 (81%) 85 (70%) 1392 (80%) 4 (2-9)
0.1170 0.8204 0.1326 0.0416
2600 (84%) 511 (72%) 357 (69%) 49 (44%) 241 (68%)
<0.0001 0.0004 <0.0001 <0.0001
TE D 630 (22%) 13 (19%) 36 (30%) 342 (20%) 6 (3-14)
EP
AC C
3 4
RI PT
0.0291 <.0001
SC
Demographics Age Male Gender Race White Black Other Hispanic Ethnicity Insurance Private Medicare Medicaid Uninsured 3M Severity Score Minor Moderate Major Extreme Ungroupable TBI Severity Mild (<1 hr LOC) Moderate (1-24 hrs LOC) Severe (24+ hrs LOC) Unspecified Length of Stay Discharge Location Home Rehabilitation Skilled Nursing Facility Longterm Acute Care Other
M AN U
2
479 (16%) 203 (28%) 160 (31%) 63 (56%) 116 (32%)
1
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Table 1. Demographic and injury related characteristics of sample at index hospitalization. N=4779
M AN U
1577 (33%) 1259 (26%) 212 (4%) 1731 (36%)
9±11.5 5 (2,10) 0-150
71.6±94.6 36.1 (22.4, 73.9) 0-1075.6
EP
AC C
SC
2804 (59%) 798 (17%) 84 (2%) 1076 (23%) 941 (20%)
RI PT
50.6±21.9 3089 (65%)
TE D
Demographics Age Male Gender Race White Black Asian Other Hispanic Ethnicity Insurance Private Medicare Medicaid Uninsured Clinical (initial trauma) LOS mean±SD median (Q1, Q3) Min-Max Total Charges (in thousands) mean±SD median (Q1, Q3) Min-Max 3M Severity Score Minor Moderate Major Extreme Ungroupable TBI Severity Mild (<1 hr LOC) Moderate (1-24 hrs LOC) Severe (24+ hrs LOC) Unspecified Admit Type Medical Emergency Trauma Urgent Other Specialization
696 (15%) 1579 (33%) 1574 (33%) 924 (19%) 6 (0.1%) 2855 (60%) 69 (1%) 121 (3%) 1734 (36%) 2050 (43%) 2527 (53%) 198 (4%) 4 (<1%)
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4233 (89%) 269 (5%) 277 (6%)
AC C
EP
TE D
M AN U
SC
RI PT
Trauma Surgery Other (Combined specializations listed for ≤1% of the patients) Not Listed
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Figure 1: Healthcare utilization between January 2006 and June 2014
RI PT
16,717 patients admitted to the trauma center 1/1/06-6/30/14 N=5,291 patients with TBI
n=512 expired during index admission
12,307 encounters
n=1,621 with no identified additional healthcare utilization captured in this database
M AN U
n=3,158 patients with additional healthcare encounters in DFW
SC
n=4,779 surviving patients with TBI
9,769 non-admission urgent
or procedural visits
AC C
EP
TE D
2538 inpatient encounters
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M AN U
SC
RI PT
Figure 2: Healthcare encounters within one year of injury
Twenty-two individuals did not have any documented services in the database during the first year after injury yet had subsequent services.
AC C
EP
TE D