Faculty Bibliography

Research Objectives: Outpatient rehabilitation is a critical piece of the traumatic brain injury (TBI) care continuum to optimize physical or cognitive recovery gains after discharge from inpatient rehabilitation. The purpose of this study is to investigate post-inpatient discharge awareness of, attitude toward, and attendance in outpatient rehabilitation. Design: Utilized data collected through TBI Model Systems (TBIMS) Form I & II interviews and additional interview at first year post-injury follow up. Setting: A large, public, urban hospital. Participants: Respondents with TBI (Mage = 48.8, SD = 18.2) were primarily male (82%), White (44%) or Hispanic (22%), single (46%), and with a college education (53%). Interventions: Not Applicable Main Outcome Measure(s): Post-discharge care interview, psychosocial and functional variables from TBIMS Form I (pre-injury, medical record abstraction) and Form II (year one follow-up). Results: Analyses were carried out on the 34 patients who were discharged to a private residence. Out of these respondents, 36.4% did not return for their outpatient follow-up appointments. Figures and tables with descriptive statistics regarding patient attitudes toward and attendance in follow-up care at 1 year post-injury will be presented across demographic and psychosocial variables (age, race, social support), functional outcomes (Functional Independence Measure [FIM], length of stay (LOS), and patient attitudes toward participating in followup care. Conclusions: These results provide insight into the risk factors, circumstances, and beliefs that hinder patient attendance in recommended outpatient follow-up. Implications for clinical care include early identification of these patients (i.e., age, level of social support) to ensure adequate education about the importance of continued therapy in order to improve long-term outcomes

Research Objectives: This study analysis examines the underlying barriers and facilitators to research recruitment within the protocol-eligible vulnerable population of the Traumatic Brain Injury Model Systems (TBIMS) research study. The difficulties behind TBI research lies in its more complicated, difficult to consent, yet eligible participants, such as those of multiple vulnerable group memberships (i.e., non-domicile, minority), those with cognitive impairments, and those lacking social support. This study seeks not only to address the question of research possible selection bias, but also identify possible risk and support factors influencing study enrollment. Design: Utilized data collected through TBI Model Systems (TBIMS) Form I & II interviews and additional interview at first year post-injury follow up. Setting: Data collected through in-person and telephone interviews and medical record abstractions from acute and rehabilitation medical records from two urban New York City TBIMS hospitals. Participants: Participants included over 300+ individuals who were admitted to two TBIMS hospitals from March 2013 through 2016. As of November 2015, participants were primarily male (80%), White (39%) or Hispanic (27%), spoke English (68%), and were an average of 52.3 years old (SD = 19.3). Interventions: Not Applicable. Main Outcome Measure(s): Demographic, psychosocial, and injury-related variables taken from TBIMS Form I (pre-injury, medical record abstraction) and Form II (year one follow-up). Preliminary results showed, slightly above half (56%) of the recruited protocol-eligible TBIMS patients agreed to participate is the study. Results: Descriptive and inferential statistics will be utilized to identify risk and support factors for protocol-eligible non-enrollment, such as demographics, degree of social support, and other jeopardizing factors, such as history of homelessness. Conclusions: Implications for clinical interventions and suggestions for decreasing refusal rates within a TBI population will be discussed

OBJECTIVE: Posttraumatic seizures (PTS) are well-recognized acute and chronic complications of traumatic brain injury (TBI). Risk factors have been identified, but considerable variability in who develops PTS remains. Existing PTS prognostic models are not widely adopted for clinical use and do not reflect current trends in injury, diagnosis, or care. We aimed to develop and internally validate preliminary prognostic regression models to predict PTS during acute care hospitalization, and at year 1 and year 2 postinjury. METHODS: Prognostic models predicting PTS during acute care hospitalization and year 1 and year 2 post-injury were developed using a recent (2011-2014) cohort from the TBI Model Systems National Database. Potential PTS predictors were selected based on previous literature and biologic plausibility. Bivariable logistic regression identified variables with a p-value < 0.20 that were used to fit initial prognostic models. Multivariable logistic regression modeling with backward-stepwise elimination was used to determine reduced prognostic models and to internally validate using 1,000 bootstrap samples. Fit statistics were calculated, correcting for overfitting (optimism). RESULTS: The prognostic models identified sex, craniotomy, contusion load, and pre-injury limitation in learning/remembering/concentrating as significant PTS predictors during acute hospitalization. Significant predictors of PTS at year 1 were subdural hematoma (SDH), contusion load, craniotomy, craniectomy, seizure during acute hospitalization, duration of posttraumatic amnesia, preinjury mental health treatment/psychiatric hospitalization, and preinjury incarceration. Year 2 significant predictors were similar to those of year 1: SDH, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Corrected concordance (C) statistics were 0.599, 0.747, and 0.716 for acute hospitalization, year 1, and year 2 models, respectively. SIGNIFICANCE: The prognostic model for PTS during acute hospitalization did not discriminate well. Year 1 and year 2 models showed fair to good predictive validity for PTS. Cranial surgery, although medically necessary, requires ongoing research regarding potential benefits of increased monitoring for signs of epileptogenesis, PTS prophylaxis, and/or rehabilitation/social support. Future studies should externally validate models and determine clinical utility.

OBJECTIVE: To use a patient-centered approach or participatory action research design combined with advanced psychometrics to develop a comprehensive patient-reported outcomes (PRO) measurement system specifically for individuals with traumatic brain injury (TBI). This TBI Quality-of-Life (TBI-QOL) measurement system expands the work of other large PRO measurement initiatives, that is, the Patient-Reported Outcomes Measurement Information System and the Neurology Quality-of-Life measurement initiative. SETTING: Five TBI Model Systems centers across the United States. PARTICIPANTS: Adults with TBI. DESIGN: Classical and modern test development methodologies were used. Qualitative input was obtained from individuals with TBI, TBI clinicians, and caregivers of individuals with TBI through multiple methods, including focus groups, individual interviews, patient consultation, and cognitive debriefing interviews. Item pools were field tested in a large multisite sample (n = 675) and calibrated using item response theory methods. MAIN OUTCOMES MEASURES: Twenty-two TBI-QOL item banks/scales. RESULTS: The TBI-QOL consists of 20 independent calibrated item banks and 2 uncalibrated scales that measure physical, emotional, cognitive, and social aspects of health-related quality of life. CONCLUSIONS: The TBI-QOL measurement system has potential as a common data element in TBI research and to enhance collection of health-related quality-of-life and PRO data in rehabilitation research and clinical settings.

OBJECTIVE: Describe the 10 year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Patients aged 16 to 55 years who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009 and had at least 3 completed follow up interviews at post-injury years 1, 2, 5 and 10 (n=3,618). MAIN OUTCOMES MEASURE: Employment RESULTS: Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relationships to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, pre-injury substance misuse, pre-injury vocational status and days of post-traumatic amnesia. Calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all post-employment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years post-injury. CONCLUSIONS: These results confirm that post-injury employment after moderate to severe TBI is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years post-injury suggests that moderate to severe TBI may have unfavorable chronic effects, and/or that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years post-injury is recommended, as are interventions that target influencing factors.

BACKGROUND: If and how much dural penetration influences long-term outcome after traumatic brain injury (TBI) is understudied, especially within the civilian population. OBJECTIVES: Using the large TBI Model Systems cohort, this study assessed and compared penetrating TBI (PTBI) and closed TBI with respect to global outcome and late seizures 2 years after injury. METHODS: After performing unadjusted PTBI versus closed TBI comparisons, multivariate regression models were built and analyzed for both outcomes by including the following additional predictors: length of unconsciousness, posttraumatic amnesia duration, hospital length of stay, age, gender, race, marital status, education level, problem substance abuse, and preinjury employment status. RESULTS: The collapsed Glasgow Outcome Scale model (n = 6111) showed significant secondary effects of PTBI with employment status. When employed before injury, individuals with PTBI were 2.62 times more likely (95% confidence interval, 1.92-3.57) to have a lower Glasgow Outcome Scale category. The final model for late seizures (n = 6737) showed a significant main effect for PTBI. Adjusting for other predictors, individuals with PTBI were 2.78 times more likely (95% confidence interval, 1.93-3.99) than those with closed TBI to be rehospitalized for a seizure. CONCLUSION: This study empirically demonstrates that penetrating injury mechanism has important prognostic implications.