C. K. Zogg1,2, R. Haring2, J. K. Canner3, A. H. Haider2, E. B. Schneider2 3Johns Hopkins University School Of Medicine,Johns Hopkins Surgery Center For Outcomes Research, Department Of Surgery,Baltimore, MD, USA 1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA
Introduction: TBI is an important cause of death and disability among older adults (≥65y), representing >20,000 deaths and 130,000 hospitalizations each year. Much of our understanding comes from work by the CDC, which conceptualized the “silent epidemic” as a TBI pyramid. At the pyramid’s base, expected to be the largest in number, were patients receiving care outside of the ED about whom little is known and for whom no estimates are available. The objective of this study was to estimate the national burden of healthcare-seeking TBI among Medicare-covered outpatients, define epidemiologic characteristics of the population, and assess for temporal and seasonal trends in outpatient presentation.
Methods: Ten years, 2004-2013, of Truven Health Analytics MarketScan Medicare claims were queried for index older adult TBI visits (≥1 CDC-defined TBI diagnosis) that were managed entirely via outpatient care (office/clinic, urgent care). Index ambulatory ED visits served as a clinically similar reference. Descriptive statistics compared differences among index outpatient visits treated in urgent care and office/clinic settings versus the ambulatory ED, including variations in demographic and clinical factors, managing providers, CDC-defined TBI diagnoses, and post-index visit ambulatory care use within 30/90/180 days. Joinpoint regressions assessed for annual changes in outpatient TBI rates per 100,000 older adult enrollees. Monthly variations in outpatient rates and estimation of the nationwide outpatient burden in 2013, inclusive of privately-insured and uninsured patients, were also compared.
Results: A total of 445,612 Medicare-covered index visits were included, representing an annual burden of 689,100 outpatient cases nationwide (750,800 including ambulatory ED)—a number which encompassed 61.0% of all known healthcare-seeking TBI among patients of this age in 2013 and which significantly increased in magnitude each year (Figure). The vast majority (88.8%) of index visits were managed in office/clinic settings (0.3% in urgent care) versus 10.9% in the ED. While demographic distributions varied across locations, clinical indications were comparable. Seasonal spikes appeared to coincide with winter weather conditions. Outpatients, on average, required 4.6 subsequent ambulatory visits within 180 days (1.3 visits within 30 days), resulting in >3.88 million annual ambulatory TBI visits nationwide.
Conclusion: There is an urgent need to consider the clinical implications and outcomes of the nearly 700,000 annual healthcare-seeking older adult TBI patients within the foundational pyramid-tier who have not been considered in previous estimates and whose clinical course has seldom been studied.
