Mortality After Discharge From Acute Care Hospitalization With Traumatic Brain Injury: A Population-Based Study

doi:10.1016/j.apmr.2009.08.151

Archives of Physical Medicine and Rehabilitation

Volume 91, Issue 1, January 2010, Pages 20-29

https://doi.org/10.1016/j.apmr.2009.08.151 Get rights and content

Abstract

Ventura T, Harrison-Felix C, Carlson N, DiGuiseppi C, Gabella B, Brown A, DeVivo M, Whiteneck G. Mortality after discharge from acute care hospitalization with traumatic brain injury: a population-based study.

Objective

To characterize mortality after acute hospitalization with traumatic brain injury (TBI) in a socioeconomically diverse population.

Design

Population-based retrospective cohort study.

Setting

Statewide TBI surveillance program.

Participants

Colorado residents with TBI discharged alive from acute hospitalization between 1998 and 2003 (N=18,998).

Interventions

Not applicable.

Main Outcome Measures

Vital status at the end of the study period (December 31, 2005) and statewide population mortality rates were used to calculate all-cause and cause-specific standardized mortality ratios (SMRs) and life expectancy compared with population mortality rates. The influence of demographics, injury severity, and comorbid conditions on time until death was investigated using age-stratified Cox proportional hazards modeling.

Results

Patients with TBI carried about 2.5 times the risk of death compared with the general population (SMR=2.47; 95% confidence interval [CI], 2.31–2.65). Life expectancy reduction averaged 6 years. SMRs were largest for deaths caused by mental/behavioral (SMR=3.84; 95% CI, 2.67–5.51) and neurologic conditions (SMR=2.79; 95% CI, 2.07–3.77) and were smaller but significantly higher than 1.0 for an array of other causes. Injury severity and older age increased mortality among young people (age <20y). However, risk factors for mortality among adults age 20 and older involved multiple domains of demographics (eg, metropolitan residence), injury-related measures (eg, falls versus vehicular incidents), and comorbidity (eg, ≥3 comorbid health conditions versus none).

Conclusions

TBI confers an increased risk of mortality in the months and years after hospital discharge. Although life expectancy is reduced across the population, the excess in mortality lessens as time since injury increases. Specific risk factors (eg, high injury severity, poor general health) pose an especially high threat to survival and should prompt an increased vigilance of health status, especially among younger patients.

Section snippets

Methods

This retrospective cohort study used a population-based sample of patients who were hospitalized with TBI and discharged alive between January 1, 1998 and December 31, 2003. The outcome of interest was length of time between the date of discharge and date of death or end of study period (December 31, 2005). Case definition and analytical methods of this study, described here, are similar to work reported previously.1, 10

Results

The 18,998 patients in the cohort contributed 83,268 person-years, and median time of follow-up on each subject was 4.4 years (range, <1–8y). Nearly 20% of cohort members were of a racial or ethnic minority, including Hispanic (14%), black (3%), Asian (1%), and Native American subjects (<1%) (table 1). Community-level median annual income among the represented zip codes in 2000 ranged between $15,000 and $150,000, with 50% of cases residing in areas with median income ranging between $35,000

Discussion

We observed high excess mortality within the first month after hospital discharge (SMR=25.20; 95% CI, 16.13–39.38). Our supplemental examination of deaths within the first postdischarge month revealed a high number of accompanying TBI diagnoses and greater injury severity compared with later deaths. For those surviving past the first month to at least 1 year postdischarge, there remained a significantly elevated mortality, emphasizing the importance of continued monitoring and care in the first

Conclusions

This research provides support for previous reporting that TBI confers a reduced life expectancy and increased risk of death in the months and years after discharge from acute hospital care. Persons with TBI and their health care support systems should engage in regular and continuous evaluation of health status in the years after injury. Despite cross-sectional estimates of reduced life expectancy attributed to TBI, the excess risk of death after TBI decreases as survival time increases.

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Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study
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Citation Excerpt :
Individuals who sustain a TBI have an increased likelihood of mortality for the first several years after brain injury, with estimates ranging from 2 to 7 times the risk relative to the general population.2–4 TBI patients have decreased overall life expectancy.3–7 Limited studies have attempted to identify independent predictors of mortality after TBI.
Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates.
This single-center, six-year (2006–2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality.
Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death.
Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.
Prevalence of suicidal ideation and suicide attempt among patients with traumatic brain injury: A meta-analysis
2022, Journal of Affective Disorders
Citation Excerpt :
In recent years, empirical studies on the relationship between TBI and suicide risk have led to increasing literature on suicide-related outcomes among TBI patients. However, most of these studies have been confounded by several methodological shortcomings, such as small sample size, single sample source, recall bias, etc. (Brenner et al., 2011; Harrison-Felix et al., 2012; Pentland et al., 2005; Richard et al., 2015; Shavelle et al., 2001; Ventura et al., 2010), and the incidence of TBI varies widely by country and region, gender and age, as well as the incidence of SI (6.3–72.7%) (Bethune et al., 2017; Fisher et al., 2020; Gutierrez et al., 2008) and SA (0.086–27.3%) (Fisher et al., 2020; Gutierrez et al., 2008; Hostetter et al., 2019). Therefore, it is challenging to appreciate the epidemiological characteristics of SI and SA in TBI patients.
Suicidality is common among patients with traumatic brain injury (TBI). This meta-analysis aimed to assess the prevalence of suicidal ideation (SI) and suicide attempt (SA) in TBI patients.
Databases including PubMed, Cochrane Library, Embase, CINAHL, Web of Science, PsycINFO, China National Knowledge Infrastructure (CNKI), VIP, WanFang Data, and Chinese Biomedical Literature Database (CBM) were searched for relevant literature from inception to 9th January 2021. Random effects models were used to estimate the prevalence of SI and SA. The methodological quality of the included studies was assessed using the modified Newcastle-Ottawa Scale. Subgroup analysis was performed based on the geographical location of the institutions.
A total of 16 studies involving 1,146,271 patients with TBI were included in our meta-analysis. The prevalence of SI and SA were 19.1% (95% CI 13.6–24.6%) and 2.1% (95% CI 1.8–2.4%), respectively, while the prevalence of SA in Asian and non-Asian countries were 2.0% (95% CI 0.3–3.7%) and 2.0% (95% CI 1.6–2.3%). Meta-regression analyses revealed that the publication year and age were positively associated, while the geographical location of the institution and sample size were negatively associated with the pooled prevalence of SI. On the other hand, the geographical location of the institution, sample size and age were negatively associated with the pooled prevalence of SA.
The overall heterogeneity between studies was high.
SI and SA are common among TBI patients. Therefore, targeted preventive measures are paramount to manage TBI-related suicide.
Life Expectancy of 1-Year Survivors of Traumatic Brain Injury, 1988-2019: Updated Results From the TBI Model Systems
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To update the life expectancy estimates according to age, sex, mobility, and feeding skills reported in the 2015 study of Brooks et al. To examine trends in survival over the past decade.
Observational cohort study.
Poisson regression and life table analysis applied to long-term follow-up data on United States (US) Traumatic Brain Injury (TBI) Model Systems patients recorded in the national database. Functional mobility and feeding skills were assessed with FIM.
A total of 14,803 persons with TBI during the years 1988-2019 who underwent inpatient rehabilitation and provided at least 1 long-term assessment of functional skills 1 year or more postinjury (N=14,803).
Not applicable.
Survival, mortality rates, and life expectancy.
Life expectancy was lower than that of the age- and sex-matched general population. Older age and severity of functional impairments were risk factors for mortality (both P<.0001 in regression models). Among ambulatory individuals, mortality was 51% (95% confidence interval, 35%-69%) higher in men than women. Life expectancy of 20-year-old women who walked well (FIM ambulation score 7) was 55 (SE=0.8) additional years to age 75, representing a reduction of 6.9 years from the normal general population figure. For 20-year-old men who walked well, the life expectancy was 49 (SE=0.5) additional years, representing a reduction of 8.1 years from normal. Life expectancies for men and women who did not walk and were fed by others were much lower. There was no significant change in mortality rates during the study period (hazard ratio, 1.008; P=.07).
There has been no significant change in the long-term survival of persons with TBI in the US since the late 1980s. The life expectancies reported here are similar to those reported in the 2015 study of Brooks et al, although they are more precise because of the larger sample size and longer follow-up.
Pre-injury health status and excess mortality in persons with traumatic brain injury: A decade-long historical cohort study
2020, Preventive Medicine
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Although evidence exists for relationships between certain pre-existing comorbid disorders and both in-hospital and all-cause mortality (Stein et al., 2010; Mushkudiani et al., 2008), uncertainty surrounds the magnitude of these associations, and the contributions of different comorbidities to the development of long-term adverse outcomes (Xiong et al., 2019). Chronic medical disorders, mental health disorders and alcohol and drug use, and a range of comorbid conditions through comorbidity indices are the most commonly reported predictors of all-cause mortality (Supplementary Table 1) (Xiong et al., 2019; Chan et al., 2017; Fuller et al., 2016; Fu et al., 2015; Jonsdottir et al., 2017; Catapano et al., 2017; Harrison-Felix et al., 2012; van der Ploeg et al., 2016; Rickels et al., 2010; Ventura et al., 2010); however, a variety of non-diagnostically specific ways were used to study and categorize these comorbidities and/or comorbidity indices (Xiong et al., 2019). By focusing almost exclusively on selective comorbid disorders within an individual, both mental and physical, that are collected via self-report measures or chart abstractions from clinical files (Xiong et al., 2019), clinicians and researchers may miss opportunities to risk-stratify patients with less common comorbidities, and those emerging from environmental adversities.
An increasing number of patients are able to survive traumatic brain injuries (TBIs) with advanced resuscitation. However, the role of their pre-injury health status in mortality in the following years is not known. Here, we followed 77,088 consecutive patients (59% male) who survived the TBI event in Ontario, Canada for more than a decade, and examined the relationships between their pre-injury health status and mortality rates in excess to the expected mortality calculated using sex- and age-specific life tables. There were 5792 deaths over the studied period, 3163 (6.95%) deaths in male and 2629 (8.33%) in female patients. The average excess mortality rate over the follow-up period of 14 years was 1.81 (95% confidence interval = 1.76–1.86). Analyses of follow-up time windows showed different patterns for the average excess rate of mortality following TBI, with the greatest rates observed in year one after injury. Among identified pre-injury comorbidity factors, 33 were associated with excess mortality rates. These rates were comparable between sexes. Additional analyses in the validation dataset confirmed that these findings were unlikely a result of TBI misclassification or unmeasured confounding. Thus, detection and subsequent management of pre-injury health status should be an integral component of any strategy to reduce excess mortality in TBI patients. The complexity of pre-injury comorbidity calls for integration of multidisciplinary health services to meet TBI patients' needs and prevent adverse outcomes.
Survival and Functional Outcomes at Discharge After Traumatic Brain Injury in Children versus Adults in Resource-Poor Setting
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An estimated 69 million people, at least 3 million of whom are children, experience TBI each year.2,3 Beyond mortality in the acute postinjury period, TBI is associated with up to 7× increased risk of death for up to 13 years after injury and an overall reduced life expectancy.4,5 Even those who survive TBI may suffer development of neuroendocrine and neuropsychiatric sequelae or lifelong impairments in physical, cognitive, social, and vocational function.6-8
More than 90% of trauma mortality occurs in low- and middle-income countries, especially in sub-Saharan Africa. Head injury is the primary driver of trauma mortality in the prehospital and in-hospital setting.
An observational study was performed on patients presenting with traumatic brain injury (TBI) from October 2016 through May 2017 at Kamuzu Central Hospital, Malawi. Bivariate analysis and logistic regression were performed to determine the odds of favorable functional outcomes and mortality after controlling for significant covariates.
Of the 356 patients with TBI, 72 (20.2%) were children <18 years of age. Males comprised 202 (87.1%) and 46 (63.9%) of the adult and pediatric cohorts, respectively. Motor vehicle crash was the leading etiology in adults and children. There was no significant difference between adult and pediatric Glasgow Coma Scale score on admission, 10.8 ± 3.9 versus 10.9 ± 3.5, respectively (P = 0.8). More adult (n = 76, 32.3%) than pediatric (n = 13, 18.1%) patients died. On multivariable analysis, pediatric patients were more likely to have a favorable outcome defined by a Glasgow Outcome Scale of good recovery or moderate disability (odds ratio 3.70, 95% confidence interval 1.22–11.17, P = 0.02) and were less likely to die after TBI (odds ratio 0.29, 95% confidence interval 0.09–0.93, P = 0.04).
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: Supported by the Colorado Traumatic Brain Injury Trust Fund Research Program (Colorado Department of Human Services). DiGuiseppi was supported in part by the Centers for Disease Control and Prevention (grant no. R49/CCR811509). The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints are not available from the author.

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Original articleMortality After Discharge From Acute Care Hospitalization With Traumatic Brain Injury: A Population-Based Study

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Arch Phys Med Rehabil

Mortality following rehabilitation in the Traumatic Brain Injury Model Systems of Care

NeuroRehabilitation

Life expectancy

The epidemiology of traumatic brain injury: a review

Epilepsia

Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths

The epidemiology and impact of traumatic brain injury: a brief overview

J Head Trauma Rehabil

Long-term mortality trends in patients with traumatic brain injury

Brain Inj

Long-term survival after traumatic brain injury: a population-based analysis

NeuroRehabilitation

Long-term survival of Medicare patients with head injury

J Trauma

Relative risk of mortality after traumatic brain injury: a population-based study of the role of age and injury severity

J Neurotrauma

Causes of death following 1 year postinjury among individuals with traumatic brain injury

J Head Trauma Rehabil

Risk of posthospitalization mortality among persons with traumatic brain injury, South Carolina 1999-2001

J Head Trauma Rehabil

Long-term causes of death after traumatic brain injury

Am J Phys Med Rehabil

Central nervous system injury surveillance data submission standards—2002

International classification of diseases, tenth revision, clinical modification (ICD-10-CM)

Original article
Mortality After Discharge From Acute Care Hospitalization With Traumatic Brain Injury: A Population-Based Study