Rural Disparities in posthospitalization. after traumatic brain injury.

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1 Rural Disparities in posthospitalization rehabilitation after traumatic brain injury. Ashley D Meagher MD, Jennifer Doorey MS, Christopher Beadles MD PhD, Anthony Charles MD MPH University of North Carolina Department of Surgery & Cecil G. Sheps Center for Health Services Research

2 Conflicts of Interest None to Disclose

3 Traumatic Brain Injury Acquired brain injury. Severity: Mild Moderate Severe

4 Traumatic Brain Injury 275,000 hospitalizations annually. Approximately $76.5 billion in yearly costs Rising rate of TBI related ER visits and hospitalizations. Rehabilitation key to long term function. ~75% of patients show functional improvement prior to discharge.

5 Rural America Roughly 62.5 million residents. Barriers to healthcare. Distance to provider Transportation Facilities

6 Rurality and Trauma Injury location: Trauma occurs in rural area, patient is rural/urban resident. Access to hospital: Longer time in transport. Higher mortality. Residential location: Trauma occurs in urban/rural area, patient is a rural resident. Important for post hospitalization care: Paucity of information on discharge destination for rural residing trauma patients.

7 Objective Evaluate effect of sub urban and rural residency on discharge destination after TBI.

8 National repository of trauma registry data. Mandatory submission by ACS verified trauma centers. Includes pre hospital, in hospital and discharge data. Discharge Destination Urban Influence Codes

9 Discharge Destination Home Home Health Skilled Nursing Inpatient Rehab No Therapy services Outpatient setting Limited time Residential setting Minimal therapy Potentially long term Inpatient setting Intensive therapy Goal to discharge home Increasing Rehabilitative Services

10 Urban Influence Codes County level numerical assignment. Developed by USDA Based on central place theory: Urban centers provide services to outlying communities. Urban Large and small metro counties Sub urban Adjacent to large and small metro counties Rural Not adjacent to metro counties

11 Hypothesis Rural and Sub urban residents are less likely to receive intensive rehabilitative services following discharge than Urban residents after controlling for pre hospital and clinical characteristics.

12 Methods NTDB retrospective review: Age 18. Moderate to severe TBI. Pre hospital variables: Age, gender, race/ethnicity, insurance status, UIC Clinical Characteristics: AIS head, GCS, ISS, LOS, MOI, trauma center level

13 TBI ,198 incidents Exclude: Age<18 (117,220) 445,978 incidents Exclude: d/c unknown, or expired (94,243) 351,795 incidents Exclude missing data: * Home UIC (161,788) * GCS-M, LOS, ISS, gender, insurance status, MOI (32,343) 157,604 incidents

14 Pre Hospital Characteristics Overall 157,604 Urban 123,593 Sub-urban 22,014 Rural 11,997 Age (yr) 48.8 ± ± ± ± 21.1 Male (%) NHW (%) Insurance (%) Private Medicare Self Pay rd Party Medicaid Other

15 Clinical Characteristics Overall 157,604 Urban 123,593 Sub-urban 22,014 Rural 11,997 GCS-Motor 5.4 ± ± ± ± 1.8 AIS 3.1 ± ± ± ± 0.9 ISS 15.1 ± ± ± ± 9.4 Discharge (%) IR SN HH Home

16 Ordered Logistic Regression Likelihood of discharge to a higher level of rehabilitation (Odds Ratio). Home Home Health Skilled Nursing Inpatient Rehab Increasing Rehabilitative Services

17 Likelihood of Discharge to Higher Level of Rehabilitation Urban Adjusted OR Reference [95% CI] Sub-urban 0.90 [0.87, 0.93] Rural 0.90 [0.86, 0.94] Race/ethnicity NHW Reference Hispanic 0.67 [0.64, 0.71] Black 0.91 [0.87, 0.95]

18 Example 18 year old white male with severe injuries Probability of discharge to inpatient rehab: Urban resident: 27% Rural resident: 23%

19 Example 65 year old white female with severe injuries Probability of discharge to inpatient rehab: Urban resident: 57% Rural resident: 50%

20 Summary Rural and sub urban TBI patients are significantly less likely to receive discharge to intensive rehabilitation than their urban counterparts.

21 Limitations Administrative Data Set: Missing data: UIC missing in ~40% of data points. Univariate analysis between missing and nonmissing datasets without apparent differences.

22 Possible Contributing Factors Geography: Accessibility of rehabilitation centers. Associated costs: Visitation. Social: Family preference. Social support. Physician and patient expectations.

23 Conclusions and Implications Rural and sub urban patients are less likely to be discharged to rehabilitation. Significantly impacts: Long term functionality and quality of life Family and community resources. Must expand access to rehabilitative services to residents of these communities.

24 Acknowledgements Anthony Charles, MD MPH Jennifer Doorey, MS Chris Beadles, MD PhD Tim Carey, MD MPH UNC Department of Surgery Sheps Center for Health Services Research NC TRaCS Institute This research was partially supported by a National Research Service Award Post Doctoral Traineeship from the Agency for Health Care Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. 5T32 HS and NIH CTSA at UNC Grant No. 2KR391203

25 Missing Data Overall 351,735 No missing 157,604 Missing 194,131 Age 48.5 ± ± ± 21 Male (%) White (%) Insurance (%) Private rd Party Medicare Medicaid Self Pay Other

26 Missing Data Overall 351,735 No missing 157,604 Missing 194,131 GCS-Motor 5 ± ± ± 2.6 AIS 3.1 ± ± ± 0.9 ISS 14 ± ± ± 9.8 Discharge (%) AIR SNF HH Home

27 Children and Elderly are more likely to sustain a TBI Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

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