S. N. Lueckel1,2, D. S. Heffernan1,3, T. Kheirbek1,3, M. D. Connolly1,3, S. F. Monaghan1,3, C. A. Adams1,3, W. G. Cioffi1,3, K. Thomas2 3Brown University,School Of Medicine,Providence, RI`, USA 1Rhode Island Hospital,Department Of Surgery Division Of Trauma Surgery And Critical Care,Providence, RI, USA 2Brown Universtiy,School Of Public Health,Providence, RI, USA
Introduction:
Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. In 2010, 2.5 million people suffered TBI at a cost of $76.5 billion. Within the survivors, TBI remains a leading contributor to long term disability. It is estimated that 5.3 million people are living with physical, emotional, cognitive and behavioral disabilities attributable to TBI, many of whom require placement in long term skilled nursing (SNFs). Despite this very large population of TBI patients, very little is known about the long term outcomes of TBI survivors, including rates of discharge to home or risk of death in long term nursing facilities.
Methods:
This is a retrospective review of the prospectively maintained Federal Minimum Data Set (MDS) combined with the CMS Vital Status database from 2012-2013. Records were reviewed for clinical characteristics upon admission to the SNF including cognitive function (CFS), ability to communicate, and motor function. Activities of daily living were reassessed at 30 days post SNF admission to calculate Functional Improvement at 30 and 60 days and 1 year (FI). Records were also reviewed for discharge to home, readmission rates and death at 30 and 60 days and 1 year. For analysis we used robust Poisson regression to estimate relative risk (RR).
Results:
Overall, 65,099 individuals were admitted to SNFs with a TBI diagnosis in the US. The mean age was 71.6 years with 26% over the age of 85yrs. Overall, poor cognitive or functional status upon presentation to a SNF was associated with increased risk for poorer outcomes. Patients who were unable to communicate upon presentation to the SNF had a 42% lower risk of showing any FI at 30 days compared to those who could communicate. Patients with motor dysfunction had a 17% lower risk of showing any FI. Patients with communication impairment and patients with motor impairment had lower risk of being discharged to home, 86% and 85% respectively. Overall, older patients (> 65yrs) with TBI had a 3.6 times higher risk of death at 30 days in SNF compared to younger patients with TBI (RR=3.6, 95%CI=2.9,4.3). The risk of death was higher in patients with poor cognitive function was (RR=8.9, 95%CI=7.4, 10.6) significant motor impairment (RR=5 95%CI=4.5, 5.6) and in patients with impairment in communication (RR=5.5, 95%CI=5.0, 6.0) compared to those without the respective deficits.
Conclusion:
Our results further suggest that among a population with TBI admitted to SNFs, the likelihood of adverse outcomes varies significantly by key clinical and demographic characteristics. Understanding this can help set expectations to patients, families, as well as providers. Moreover, this data might help guide future therapies and calls for dedicated TBI rehabilitation facilities.