Traumatic Brain Injury Model Systems Research Articles

U.S. vs. Foreign Nativity and 10-Year Trajectories of Mental Health after Traumatic Brain Injury: A Model Systems Study.

Previous research has found racial and ethnic disparities in life satisfaction, depression, and anxiety after traumatic brain injury (TBI). However, limited studies have examined differences in these variables between U.S.- and foreign-born individuals with TBI. The purpose of this study was to examine whether differences exist in mental health outcomes between U.S.- and foreign-born individuals with TBI at 1, 2, 5, and 10 years after injury, as well as examine whether demographic and injury-related characteristics account for these differences. Participants were 8289 individuals with TBI who identified as U.S.-born and 944 who identified as born outside the U.S. in the TBI Model Systems study. Participants completed measures of mental health outcomes at 1, 2, 5, and 10 years after injury. Foreign-born individuals with TBI had comparable levels of depression and anxiety trajectories to U.S.-born individuals, yet higher life satisfaction trajectories, even after controlling for demographic and injury-related variables. Rehabilitation professionals should consider in their clinical work the mechanisms that likely influence mental health outcomes among foreign-born individuals, including family-based values that increase resilience, as well as the possible under-reporting of mental health symptoms along the lines of cultural norms.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study.

Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI. Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition). This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review. Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported). Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors. Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

Depression, Anxiety, and Suicidality in Individuals With Chronic Traumatic Brain Injury Before and During the COVID-19 Pandemic: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study

ObjectiveTo examine the prevalence, severity, and correlates of depression, anxiety, and suicidal ideation in people with traumatic brain injury (TBI) assessed before and during the COVID-19 pandemic. DesignRetrospective cohort study using data collected through the Traumatic Brain Injury Model Systems (TBIMS) network at 1, 2, 5, 10, 15, 20, 25, or 30 years post TBI. SettingUnited States–based TBIMS rehabilitation centers with telephone assessment of community residing participants. ParticipantsAdults (72.4% male; mean age, 47.2 years) who enrolled in the TBIMS National Database and completed mental health questionnaires prepandemic (January 1, 2017 to February 29, 2020; n=5000) or during pandemic (April 1, 2022 to June 30, 2021; n=2009) (N=7009). InterventionsNot applicable. Main Outcome MeasuresPatient Health Questionnaire-9 and Generalized Anxiety Disorder-7 questionnaire. ResultsSeparate linear and logistic regressions were constructed with demographic, psychosocial, injury-related, and functional characteristics, along with a binary indicator of COVID-19 pandemic period (prepandemic vs during pandemic), as predictors of mental health outcomes. No meaningful differences in depression, anxiety, or suicidal ideation were observed before vs during the COVID-19 pandemic. Correlations between predictors and mental health outcomes were similar before and during the pandemic. ConclusionsContrary to our predictions, the prevalence, severity, and correlates of mental health conditions were similar before and during the COVID-19 pandemic. Results may reflect generalized resilience and are consistent with the most recent findings from the general population that indicate only small, transient increases in psychological distress associated with the pandemic. While unworsened, depression, anxiety, and suicidal ideation remain prevalent and merit focused treatment and research efforts.

Associations of Military Service History and Health Outcomes in the First Five Years After Traumatic Brain Injury.

For many years, experts have recognized the importance of studying traumatic brain injury (TBI) among active-duty service members and veterans. A majority of this research has been conducted in Veterans Administration (VA) or Department of Defense settings. However, far less is known about military personnel who seek their medical care outside these settings. Studies that have been conducted in civilian settings have either not enrolled active duty or veteran participants, or failed to measure military history, precluding study of TBI outcomes by military history. The purpose of the present study was to determine associations between military history and medical (prevalence of 25 comorbid health conditions), cognition (Brief Test of Adult Cognition by Telephone), and psychological health (Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7, suicidality [9th item from PHQ-9]) in the first 5 years after TBI. In this prospective study, we analyzed data from the TBI Model Systems National Database. Participants were 7797 individuals with TBI admitted to one of 21 civilian inpatient rehabilitation facilities from April 1, 2010, to November 19, 2020, and followed up to 5 years. We assessed the relationship between military history (any versus none, combat exposure, service era, and service duration) and TBI outcomes. We found specific medical conditions were significantly more prevalent 1 year post-TBI among individuals who had a history of combat deployment (lung disorders, post-traumatic stress disorder [PTSD], and sleep disorder), served in post-draft era (chronic pain, liver disease, arthritis), and served >4 years (high cholesterol, PTSD, sleep disorder). Individuals with military history without combat deployment had modestly more favorable cognition and psychological health in the first 5 years post-injury relative to those without military history. Our data suggest that individuals with TBI with military history are heterogeneous, with some favorable and other deleterious health outcomes, relative to their non-military counterparts, which may be driven by characteristics of service, including combat exposure and era of service.

Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness

ABSTRACT Objective To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation. Design Retrospective cohort. Setting NIDILRR and VA TBI Model Systems (TBIMS) centers. Participants 396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC). Main Outcome Measure Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes. Results VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of “violent” injury types. Conclusions This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.

Causes of Mortality Among Veterans Previously Hospitalized After Traumatic Brain Injury

<h3>Research Objectives</h3> To examine mortality rates and causes among Veterans with traumatic brain injury (TBI) following discharge from inpatient rehabilitation. <h3>Design</h3> Secondary analysis; Cohort study. <h3>Setting</h3> Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. <h3>Participants</h3> Persons enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) who were admitted to rehabilitation within one year of TBI and discharged (alive) from rehabilitation between 01/01/2009 and 03/31/2020, and who died after rehabilitation discharge (N=82). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Mortality. <h3>Results</h3> The mortality rate was 8.3% for participants within this study's time frame. Most deaths (46.9%) occurred between 2 and 5 years from discharge. Reasons for death (among the known causes: 67.1%) were as follows: external causes of injury (29%), circulatory (22%), respiratory (18%), digestive (13%), neoplasm (9%), nervous system (7%), and infectious disease (2%). <h3>Conclusions</h3> Overall mortality rate was comparable to research in the civilian TBIMS (9-10%). Prior research implicated circulatory conditions as the most common cause of death, but in this study, the primary reasons were external causes (e.g., late effects of intracranial trauma; suicide). Digestive conditions (e.g., alcoholic liver disease) were the fourth most common cause of death yet a negligible cause in the general TBI population. Implications of the current findings include targeted clinical interventions for prevention or treatment of causes of mortality among veterans following discharge. <h3>Author(s) Disclosures</h3> Supported in part by NIDILRR [grant #90DPTB0002] (Hammond). Conducted with resources and use of facilities at the following: Hunter Holmes McGuire VA, Richmond, VA; James A. Haley VA, Tampa, FL; Minneapolis VA, Palo Alto VA, and South Texas VA. The authors declare no conflicts of interest. The views expressed here are the authors' and do not necessarily represent official policy/position of any federal government agency. This work was prepared under Contract HT0014-21-C-0012 [DHA Contracting Office (CO-NCR) HT0014] and defined as U.S. Government work under Title 17 U.S.C.§101. Per Title 17 U.S.C.§105, copyright protection is not available. For more information, contact TBICOEinfo@mail.mil. UNCLASSIFIED

Principal Component Analysis of the Traumatic Brain Injury Rehabilitation Needs Survey: Comparison of Three Models

<h3>Research Objectives</h3> To examine the higher-order structure of the Rehabilitation Needs Survey (RNS) and explore the internal consistency of the identified components. <h3>Design</h3> Principal Components Analysis; Cohort study. <h3>Setting</h3> Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. <h3>Participants</h3> Persons enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) who completed a five-year post-TBI follow-up interview (N=378; 96% male, age M=34.8; SD=14.0). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> RNS. <h3>Results</h3> The Kaiser Criterion resulted in a four-component solution with only three components containing ≥ 3 items (Cronbach alphas 0.837 to 0.900). The scree plot method resulted in a two-component solution with both containing ≥ 3 items (Cronbach alphas 0.826 to 0.901). Parallel analysis resulted in a three-component solution, all containing ≥ 3 items (Cronbach alphas 0.608 to 0.901). Twenty of the 21 items had acceptable corrected item-total correlations. The average corrected item-total correlations were 0.589 (range 0.224 to 0.715), 0.593 (range 0.434 to 0.712), and 0.602 (range 0.378 to 0.573) across the 4-, 2-, and 3-component solutions, respectively. There were between 7-9 cross-loading items depending on the model. Overall, items loaded on to components representing Activities/Participation and Body Functioning domains consistently and Vocation/Productivity inconsistently. <h3>Conclusions</h3> The three-component solution of the RNS appeared to be the clinically useful model that accounted for all 21 items with at least three items and minimally acceptable internal consistency. Although there were several cross-loading items, they refer to complex rehabilitation needs that are influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination. <h3>Author(s) Disclosures</h3> Funding: GDIT subcontract from DHA (Richardson [HT0014-21-C-0012]) and NIDILRR (O'Neil-Pirozzi, [#90DPTB0011], Walker, [#90DP0033]). This research was conducted with James A. Haley Veterans' Hospital resources and use of facilities. The views and/or findings are those of the authors and not official policy of the U.S. Departments of Defense, Veterans Affairs, Defense Health Agency, or any other federal agency. No official endorsement should be inferred.

Network Analysis of Depression, Anxiety, and Social Participation in Individuals with Traumatic Brain Injury

<h3>Research Objectives</h3> To investigate the relationship between anxiety symptoms, depression symptoms, and social participation in individuals with traumatic brain injury (TBI) at one-year post-injury. <h3>Design</h3> We used network analysis in a cross-sectional sample of individuals with TBI to understand the complexity of relationships between anxiety symptoms, depression symptoms, and social participation. In this approach, each variable represents a node and edges represent the link between nodes. Network models are based on partial correlations, which measure the association between different variables while controlling for all other variables in the network. <h3>Setting</h3> General community. <h3>Participants</h3> 3,621 participants from the Traumatic Brain Injury Model System national database (https://osf.io/a4xzb/) who completed the one-year follow-up after their hospitalization. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> The primary outcome measures were the nine depression symptoms measured by the Patient Health Questionnaire-9 (PHQ-9), the seven anxiety symptoms measured by the Generalized Anxiety Disorder-7 (GAD-7), and four social participation factors measured by social sub-domain in Participation Assessment with Recombined Tools – Objective (PART-O). <h3>Results</h3> There was a strong relationship between the GAD-7 items, "Not being able to stop or control worrying" and "Worrying too much about different things". We also found a strong relationship between the PHQ-9 items, "Feeling down, depressed, or hopeless" and "Feeling bad about yourself - or that you are a failure". There was moderate relationship between the PART-O items "Amount of times socialized with friends in a week" and "Amount of times Internet was used for communication in a week" and "Amount of times socialized with family in a week" and "Amount of times socialized with friends in a week". However, there was weak to no relationship between items across the anxiety, depression, and social participation domains. <h3>Conclusions</h3> Results suggest that specific depression and anxiety symptoms are differently associated with each other. This highlights the importance of analyzing individual symptoms rather than focusing on the aggregate of depression and anxiety symptoms. Future directions involve investigating how symptoms of anxiety and depression and social participation interact at different time points post-injury. <h3>Author(s) Disclosures</h3> None.

Comparing Marijuana and Opioid Misuse and Behavioral Health Outcomes in Moderate-Severe Traumatic Brain Injury

<h3>Research Objectives</h3> To operationalize cut points for "Opioid Misuse" and "Marijuana Use" using the Traumatic Brain Injury Model Systems (TBIMS) Pain Collaborative Dataset and to describe the interaction of opioid misuse and marijuana on behavioral and psychosocial outcomes. <h3>Design</h3> Cross-sectional analysis of TBIMS Pain Collaborative data. <h3>Setting</h3> Community. <h3>Participants</h3> Persons with TBI (n =2,314) enrolled in the TBIMS National Database who completed the Pain Collaborative survey. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Proportion of opioid misusers as classified by reporting using more than the prescribed dosage of opioids or using non-prescribed opioids; distribution of opioid misuse across categories of marijuana use; proportion and significance of substance and alcohol use and clinically significant PTSD (PTSD checklist-5), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and sleep quality (Pittsburg Sleep Quality Index). <h3>Results</h3> Among opioid users (n = 898, 38.8% of sample), there were 106 (11.8% of opioid users) who reported misusing opioids. There was statistically significant variation among the different Opioid misuse/Marijuana Categories in demographics (age), injury characteristics (cause of injury, GCS) and behavioral/psychosocial measures such as substance/alcohol use, PTSD symptoms, depression, anxiety, and sleep quality (p< 0.01). Those who misused opioids and/or used marijuana had higher rates of clinically significant behavioral outcomes than those who did not misuse opioids/and or used marijuana. <h3>Conclusions</h3> It is important to understand how people use opioids and marijuana after TBI as there is an association with poorer behavioral health outcomes among substance users. These findings can help clinicians discuss the impacts of substance use on health outcomes with individuals with TBI and chronic pain. <h3>Author(s) Disclosures</h3> This work was supported by two grants from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPTB0017). NIDILRR is a center within the Administration for Community Living (ACL), Department of Health and Human Services (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.

Polysomnographic Differences Following Moderate-Severe Traumatic Brain Injury (TBI) Among Individuals With Chronic Pain

Research Objectives To determine is differences in objectively measured sleep related respiration exists between chronic pain cohorts post-TBI. Design Longitudinal, retrospective cohort study. Setting Six TBI Model Systems inpatient rehabilitation centers. Participants 66 patients (mean age 42, 60% Caucasian, 82% male) admitted for neurorehablitation following injury were recruited to participate in a diagnostic effectiveness trial of polysomnography (PSG) and were followed between one and two-years post-injury as part of the TBIMS Pain Collaboratory study. Interventions Non-intervention study. Fully attended, level-1 PSG, the criterion standard for sleep apnea diagnosis. Main Outcome Measures PSG-derived respiratory indices and chronic pain status. Results Three-quarters of participants met criteria for sleep apnea shortly after injury and approximately 61% endorsed chronic pain following TBI. Pairwise comparisons between those who did versus those who did not endorse chronic pain at follow-up revealed that chronic pain was associated with categorically worse apnea hypopnea indices (AHI) for both obstructive (15.7 versus 11.1 events per hour of sleep) and central sleep apneas (2.6 versus 0.8 events per hour). Additionally, those who went on to experience chronic pain were found to have worse oxygenation indices (19.6 events per hour), relative to their no pain counterparts (7.9 events per hour). Conclusions This study is the first to report on an association between objective, PSG-derived respiratory indices and chronic pain status following moderate to severe TBI, finding that worse sleep-related respiratory indices early in the recovery from TBI is associated with chronic pain at long-term follow-up. Sleep apnea is an important modifiable factor following that may contribute to long-term pain-related outcomes, but further research is needed to determine whether a causal link exists. Author(s) Disclosures PCORI, CER-1511-33005; VA TBI Model Systems Program of Research; GDIT; NIDILRR 90DPTB0008. Clinicaltrial.gov Registration Number: NCT03033901 To determine is differences in objectively measured sleep related respiration exists between chronic pain cohorts post-TBI. Longitudinal, retrospective cohort study. Six TBI Model Systems inpatient rehabilitation centers. 66 patients (mean age 42, 60% Caucasian, 82% male) admitted for neurorehablitation following injury were recruited to participate in a diagnostic effectiveness trial of polysomnography (PSG) and were followed between one and two-years post-injury as part of the TBIMS Pain Collaboratory study. Non-intervention study. Fully attended, level-1 PSG, the criterion standard for sleep apnea diagnosis. PSG-derived respiratory indices and chronic pain status. Three-quarters of participants met criteria for sleep apnea shortly after injury and approximately 61% endorsed chronic pain following TBI. Pairwise comparisons between those who did versus those who did not endorse chronic pain at follow-up revealed that chronic pain was associated with categorically worse apnea hypopnea indices (AHI) for both obstructive (15.7 versus 11.1 events per hour of sleep) and central sleep apneas (2.6 versus 0.8 events per hour). Additionally, those who went on to experience chronic pain were found to have worse oxygenation indices (19.6 events per hour), relative to their no pain counterparts (7.9 events per hour). This study is the first to report on an association between objective, PSG-derived respiratory indices and chronic pain status following moderate to severe TBI, finding that worse sleep-related respiratory indices early in the recovery from TBI is associated with chronic pain at long-term follow-up. Sleep apnea is an important modifiable factor following that may contribute to long-term pain-related outcomes, but further research is needed to determine whether a causal link exists.

Impact of Post-Traumatic Amnesia on Traumatic Brain Injury (TBI) First Year Hospitalization Costs in TBIMS

Research Objectives: Examine the association between Posttraumatic Amnesia (PTA) duration and first year hospitalization costs in military servicemembers and veterans (SM/Vs) with TBI. <h3>Design</h3> Multivariable models of merged datasets from the Veterans Affairs TBI Model Systems (TBIMS) national database containing TBI clinical characterization including PTA and Veterans Health Administration (VHA) administrative cost data. <h3>Setting</h3> Five VA Polytrauma Rehabilitation Centers. <h3>Participants</h3> TBIMS participants (N=910 veterans and 77 active-duty service members) who received inpatient rehabilitation at one of the five Polytrauma Rehabilitation Centers between 2010-2020 and were admitted and discharged from rehabilitation within 1 year of their TBI. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> acute care, rehabilitation, intensive care unit and surgery costs in VA hospitals. <h3>Results</h3> The total unadjusted mean first year cost was $149,943 per patient for those with PTA< 24 hours and $351,157 for those with PTA≥24 hours. Significant covariates in adjusted modeling included: age, time from TBI to rehabilitation, DRS on admission, drug abuse comorbidity, penetrating mechanism of injury, and PTA duration. Penetrating mechanism of injury had the highest impact with $80,886 increase in rehabilitation cost, relative to vehicular injury. For each additional day of PTA, costs were increased for rehabilitation ($1,324), surgery ($38) and ICU ($78) care. <h3>Conclusions</h3> This study, the first to evaluate factors related to cost of VHA hospitalization in the first year following TBI for SM/Vs, shows the impacts of severity measured by PTA duration and penetrating mechanism. We also show average total costs in the first year were far higher than the Veterans Equitable Resource Allocation (VERA) highest allocation to VA facilities for a Veteran treated in a PRC of $77,964 for FY 2021. <h3>Author(s) Disclosures</h3> The authors have no conflict of interest to disclose.

Trajectories Of Life Satisfaction In Hispanics Over The 10 Years After Traumatic Brain Injury

<h3>Research Objectives</h3> To identify the trajectories of life satisfaction at 1 to 10 years post-TBI and to examine which demographic, injury and rehabilitation characteristics at the time of injury are associated with those trajectories. <h3>Design</h3> Hierarchical linear modeling (HLM) was used to examine baseline predictors of trajectories of life satisfaction among Hispanic individuals across 1, 2, 5, and 10 years after TBI. <h3>Setting</h3> TBI Model System Database. <h3>Participants</h3> This study included 1,051 Hispanic individuals from the multi-site, longitudinal TBI Model Systems (TBIMS) database, sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Individuals were enrolled in the study after sustaining a TBI and while undergoing inpatient rehabilitation at a TBIMS site and were included if they completed at least one Satisfaction with Life Scale at 1, 2, 5, or 10 years after TBI. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The primary outcome measure of interest was life satisfaction, measured by the Satisfaction with Life Scale (SWLS; Diener et al., 1985) at 1, 2, 5, and 10 years post-TBI. <h3>Results</h3> A linear (straight-line) movement of life satisfaction trajectories over time was the best fit to the data. Life satisfaction increased over time, with higher overall trajectories for Hispanic individuals who were partnered at baseline, born outside the U.S., and who experienced a non-violent cause of injury. There were no significant interactions for time with any of these main effect predictors, suggesting no differential change over time in life satisfaction trajectories as a function of these characteristics. <h3>Conclusions</h3> Results revealed increases in life satisfaction over time among Hispanic individuals with TBI and shed light on critical risk and protective factors that may inform targeted rehabilitation and intervention services with this underserved group. <h3>Author(s) Disclosures</h3> None.

Factors Associated With Receiving Inpatient Rehabilitation After Traumatic Brain Injury in A County Hospital System

<h3>Research Objectives</h3> To characterize factors associated with inpatient rehabilitation for individuals with Traumatic Brain Injury (TBI) presenting to an Emergency Department (ED) at a local county hospital. <h3>Design</h3> Retrospective Chart Review. <h3>Setting</h3> Emergency Department. <h3>Participants</h3> Patients (n=904) with International Classification of Diseases (ICD) codes consistent with possible TBI (i.e., motor vehicle collisions, motor vehicle accidents, falls, polytrauma, traumatic brain injury, and concussion). <h3>Interventions</h3> Not Applicable. <h3>Main Outcome Measures</h3> Inpatient rehabilitation (Yes/No) after moderate-severe TBI as defined by the TBI Model Systems criteria (trauma-related imaging abnormalities, loss of consciousness >30 minutes, post-traumatic amnesia >24 hours, and/or Glasgow Coma Scale score < 13). <h3>Results</h3> Of the 904 patients, 152 met criteria for a moderate-severe TBI based on the TBI Model Systems criteria. Most of the patients with TBI (67.1%) went home after their time in the ED and did not go directly to inpatient rehabilitation. Compared to the patients that did receive inpatient rehabilitation (n=31), those that did not (n=121) were more likely to be uninsured (21.5% vs. 6.5%), Spanish speakers (20.7% vs. 9.7%), and ethno-racial minorities (57.9% vs. 35.5%). Additionally, patients that received inpatient rehabilitation sustained more severe injuries as noted by lower GCS scores, intubation/sedation at time of admission, or not being able to walk or swallow at discharge from the ED. <h3>Conclusions</h3> In our study, similar to prior research, factors like insurance status,3 race,4,5,6 primary language spoken, and injury severity differed between patients that did versus those that did not receive inpatient rehabilitation. Future research should assess potential reasons for these differences and work to improve access to rehabilitation after TBI. <h3>Author(s) Disclosures</h3> The authors report no conflicts of interest.

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

Research has found that Hispanics with traumatic brain injury (TBI) have reduced functional outcomes compared to non-Hispanic Whites, including lower probabilities of post-injury employment. However, previous studies were cross-sectional, combined racial/ethnic minority groups, and did not examine the factors that predict return to work of Hispanics longitudinally. To determine the demographic and injury-related predictors of employment probability trajectories during the first 10 years after TBI. 1,346 Hispanics in the TBI Model Systems Database were included. Hierarchical linear modeling was used to examine baseline predictors of employment probability trajectories across this time period. Employment probability demonstrated a quadratic movement over time, with an initial increase followed by a plateau or slight decrease. Hispanics with TBI had higher employment probability trajectories if they had been younger at the time of injury, spent less time in posttraumatic amnesia, had greater years of education, had been employed at the time of injury, had higher annual earnings at the time of injury, and had experienced a non-violent mechanism of injury. Culturally adapted treatment programs with a focus on early intervention incorporating vocational rehabilitation and employment programs for Hispanics with TBI who present with these risk factors are needed.

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study.

The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury. Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC). Five VA PRCs. Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study. PART-O. Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 . Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Racial/Ethnic Differences in Arrest Probability Trajectories after Traumatic Brain Injury: A Model Systems Study.

Background: Previous literature has documented racial/ethnic differences in traumatic brain injury (TBI) risk, cause, treatment, and rehabilitation. The purpose of the current study was to investigate potential racial/ethnic differences in arrest probability trajectories over the first 10 years after TBI and whether injury and sociodemographic characteristics accounted for these differences. Methods: The current study included 13,195 participants with moderate-to-severe TBI in the TBI Model Systems National Database who had arrest data from at least one follow-up time point (Years 1, 2, 5, and/or 10). A series of hierarchical linear models assessed racial/ethnic differences in trajectories of arrest probability over these 10 years post-injury and then included socio-demographic and injury-related covariates. Results: White individuals with TBI had lower arrest probability trajectories than Black and Native American individuals, and Asian individuals with TBI had lower arrest probability trajectories than White, Black, Latinx, and Native American persons. In many cases, racial/ethnic disparities persisted even when injury and sociodemographic characteristics were covaried. Conclusion: These results suggest that rehabilitation clinicians should assess for post-injury arrest risk factors such as age, sex, education, pre-injury unemployment, arrest history, and substance abuse, particularly in Black, Latinx, and Native American groups, and integrate programming to lessen post-injury arrest probability and improve overall rehabilitation outcomes.

Barriers and Facilitators to Accessing Rehabilitation Health Care: A Veterans Affairs Traumatic Brain Injury Model Systems Qualitative Study

ObjectiveTo compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups. DesignQualitative descriptive study guided by an access to health care services conceptual framework. SettingFive Veterans Affairs (VA) polytrauma rehabilitation centers. ParticipantsSMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe). Main Outcome MeasuresBarriers and facilitators accessing care. ResultsThe main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services. ConclusionsBarriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability.

Obstructive sleep apnea is associated with worse cognitive outcomes in acute moderate-to-severe traumatic brain injury: A TBI Model Systems study

ObjectiveTo examine the relationship between polysomnography-classified obstructive sleep apnea (OSA) severity and cognitive performance in acute moderate-to-severe traumatic brain injury (TBI). MethodThis was a cross-sectional, secondary analysis leveraging data from a clinical trial (NCT03033901) and TBI Model Systems. Sixty participants (mean age = 50 ± 18y, 72% male, 67% white) with moderate-to-severe TBI from five civilian rehabilitation hospitals were assessed at one-month post-injury. Participants underwent Level 1 polysomnography. OSA severity was classified as mild, moderate, and severe using the Apnea-Hypopnea Index (AHI). Associations between OSA metrics of hypoxemia (nadir and total time spent below 90%) and AHI with cognition were examined. Cognition was assessed with the Brief Test of Adult Cognition by Telephone (BTACT), which is comprised of six subtests assessing verbal memory, attention/working memory, processing speed, language, and executive function. ResultsOver three-quarters of this acute TBI sample (76.7%) were diagnosed with OSA (no OSA n = 14; mild OSA n = 19; moderate/severe OSA n = 27). After adjustment for age, gender, and education, those with OSA had worse processing speed, working memory, and executive functioning compared to those without OSA. Compared to those with moderate/severe OSA, those with mild OSA had worse working memory and executive function. ConclusionsOSA is highly prevalent during acute stages of TBI recovery, and even in mild cases is related to poorer cognitive performance, particularly in the domains of attention/working memory and executive functioning. Our results support the incorporation of OSA diagnostic tools and interventions into routine clinical care in rehabilitation settings.

Trajectories of Cognitive and Motor Functional Independence in Hispanic Individuals During the 10 yrs After Traumatic Brain Injury.

This study examined demographic and injury-related predictors of cognitive and motor functional independence in Hispanics with traumatic brain injury at years 1, 2, 5, and 10 after hospital discharge. Hispanic participants ( n = 1360) from the TBI Model Systems Study were included if they had at least one Functional Independence Measure (FIM) Cognitive and Motor score at any time point (years 1, 2, 5, or 10). Hierarchical linear modeling was used to examine baseline predictors of FIM Cognitive and Motor trajectories across this period. FIM Cognitive trajectories showed a quadratic movement (initial increase followed by a plateau or slight decrease), whereas FIM Motor trajectories showed a cubic movement (initial increase, followed by a plateau, then another increase). Higher FIM Cognitive trajectories were predicted by younger age, shorter length of posttraumatic amnesia, higher education, and having experienced a nonviolent mechanism of injury. Higher FIM Motor trajectories were predicted by younger age, shorter posttraumatic amnesia, and a nonviolent mechanism of injury. The baseline predictors of functional trajectories identified may help create tailored, evidence-based rehabilitation interventions along the continuum of recovery during the first 10 yrs for Hispanics with traumatic brain injury at risk for reduced functional outcomes.

Distal and Proximal Predictors of Rehospitalization Over 10 Years Among Survivors of TBI: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

To describe the rates and causes of rehospitalization over a 10-year period following a moderate-severe traumatic brain injury (TBI) utilizing the Healthcare Cost and Utilization Project (HCUP) diagnostic coding scheme. TBI Model Systems centers. Individuals 16 years and older with a primary diagnosis of TBI. Prospective cohort study. Rehospitalization (and reason for rehospitalization) as reported by participants or their proxies during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. The greatest number of rehospitalizations occurred in the first year postinjury (23.4% of the sample), and the rates of rehospitalization remained stable (21.1%-20.9%) at 2 and 5 years postinjury and then decreased slightly (18.6%) at 10 years postinjury. Reasons for rehospitalization varied over time, but seizure was the most common reason at 1, 2, and 5 years postinjury. Other common reasons were related to need for procedures (eg, craniotomy or craniectomy) or medical comorbid conditions (eg, diseases of the heart, bacterial infections, or fractures). Multivariable logistic regression models showed that Functional Independence Measure (FIM) Motor score at time of discharge from inpatient rehabilitation was consistently associated with rehospitalization at all time points. Other factors associated with future rehospitalization over time included a history of rehospitalization, presence of seizures, need for craniotomy/craniectomy during acute hospitalization, as well as older age and greater physical and mental health comorbidities. Using diagnostic codes to characterize reasons for rehospitalization may facilitate identification of baseline (eg, FIM Motor score or craniotomy/craniectomy) and proximal (eg, seizures or prior rehospitalization) factors that are associated with rehospitalization. Information about reasons for rehospitalization can aid healthcare system planning. By identifying those recovering from TBI at a higher risk for rehospitalization, providing closer monitoring may help decrease the healthcare burden by preventing rehospitalization.