Discharges against medical advice (DAMA) have been considered predictors of adverse outcomes for patients in acute care and psychiatric hospitals. However, little is known about the profile of patients who discharge AMA admitted to rehabilitation hospitals. The aims of this study were to provide a profile of patients who received inpatient rehabilitation services following a traumatic brain injury (TBI) who discharged AMA and to compare this group with the regular discharge group.
Retrospective cohort study.
Hospital discharge data from two national administrative databases were reviewed for the years 2001-2006.
The databases yielded 1559 cases of TBI (average length of stay?=?51 days). Of these, 31 (2.0%) had recorded DAMA events: one in 50 patients left rehabilitation against medical advice. Compared to regular discharge (n?=?1247), DAMA was significantly associated with unemployment, intentional injury, higher motor functions at admission and shorter length of stay. Known factors for DAMA in acute hospitals, such as male sex, young age and substance abuse history, were not significant.
Careful screening and assessment of patients who discharge AMA could enable better prevention and management strategies, thus improving health outcomes and enhancing healthcare delivery.
To investigate the characteristics and inpatient rehabilitation outcomes of persons who sustained a traumatic brain injury (TBI) resulting from physical assault - a form of intentional TBI - and compare these outcomes to those of persons with TBI resulting from other aetiologies.
A prospective population-based cohort study using inpatient rehabilitation data from Canadian population-based administrative databases for the fiscal years 2001-2006. Outcome measures were measures of functional independence (motor and cognitive), as measured by the FIM™ Instrument, and discharge destinations.
Characteristics associated with intentional TBI were being male, younger in age and unemployed; living alone and having a greater likelihood of alcohol/drug abuse prior to admission. The intentional TBI group showed poorer total functional gains at discharge from inpatient rehabilitation. Multivariate regression analyses showed that persons with intentional injury were less likely to be discharged home.
Persons with TBI from physical assault are a distinct clinical group in Canadian inpatient rehabilitation settings. These findings can support clinicians in determining proper assessment, management, discharge planning and post-rehabilitation care that target specific needs of persons with TBI resulting from physical assault.
Clinicians should have appropriate training to properly assess the mental health status of this patient group. Inpatient rehabilitation facilities should be prepared to provide services targeting psychosocial, substance abuse and interpersonal relationship issues to persons with a TBI from physical assault while patients are still within a hospital setting. Follow-up clinical care and community support services are warranted for those with intentional TBIs, including provision of occupational rehabilitation services, such as vocational rehabilitation. The discharge team should be responsible for ensuring appropriate discharge to community in the absence of family or other advocates on behalf of the patient.
Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada.
A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective.
Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65% of the total treatment cost in the first year overwhelming all other cost components.
The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.
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Discharge against medical advice (DAMA) have consistently been reported as causing adverse outcomes for both patients and service providers. However, little is known about the DAMA of patients with traumatic brain injury (TBI). The objectives of this study were to develop a risk profile of DAMA patients in the TBI population, to examine factors associated with DAMA occurrence, and to examine specifically whether injury intention (unintentional vs. intentional) is a significant predictor of DAMA.
A retrospective cohort study was conducted using hospital discharge data obtained from the Minimal Data Set (MDS) of the Ontario Trauma Registry for the years 1993/1994 and 2000/2001 on TBI patients aged 15 to 64 years.
The MDS review yielded 15,684 cases of TBI with an average length of stay of 2.7 days. Of these, 446 (2.84%) had recorded DAMA events. When compared with patients with unintentional TBI, DAMA was significantly associated with intentional injuries in those with self-inflicted TBI (adjusted odds ratio [aOR] = 1.97; 95% confidence interval [CI], 1.36-2.84) and other-inflicted TBI (aOR = 2.00; CI, 1.53-2.62). DAMA was also associated with younger age and a history of alcohol/drug abuse (aOR = 3.50; CI, 2.85-4.30).
TBI patients who leave hospital against medical advice are a high-risk population. Early identification of these patients could allow implementation of better prevention and management strategies, thus improving health outcomes and enhancing healthcare delivery.
We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario.
We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004-2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions.
The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (-8.3 points, 95% CI -11.1 to -5.5) and poorer mental health status (-6.0 points, 95% CI -8.3 to -3.7).
Prior traumatic brain injury is very common among homeless people and is associated with poorer health.
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Traumatic brain injury (TBI) occurring in the workplace carries major economic repercussions such as lost wages and hospital costs. Little is known about the profile of risk factors for work-related traumatic brain injury.
This study describes the pre-injury demographic characteristics, injury-related characteristics and outcomes of work-related TBI and compares them with those of non work-related TBI. This study aims to provide profiles of work-related TBI to improve our understanding and awareness of TBI in the workplace and to better inform prevention efforts.
Cross-sectional study using the Comprehensive Data Set (CDS) of Ontario (Canada) Trauma Registry (OTR) from 1993 to 2001. Cases with the ICD-9-CM codes for head injury were included in the database of serious injuries from lead trauma hospitals.
The study identified 950 (7.3%) people with work-related TBI. Pre-injury demographics and injury-related characteristics of work-related TBI were significantly different from non work-related TBI such as age, gender, mechanisms of injury, Injury Severity Score, length of stay and in-hospital death.
This research provides the first comprehensive overview of work-related TBI based on Canadian data. It identifies high risk profiles to better target prevention.
Traumatic brain injury (TBI) is a leading cause of death and disability in developed countries. We document trends in TBI-related hospitalizations in Ontario, Canada, between April 1992 and March 2002, focusing on relationships between inpatient hospitalization rates, age, sex, cause of injury, severity level, and in-hospital mortality.
Information on all acute hospital separations in Ontario with a diagnosis of TBI was analyzed using logistic regression.
Hospitalization rates fell steeply among children and young adults but remained stable among adults aged 66 and older. The proportion of TBI hospitalizations with mild injuries decreased from 75% to 54%, whereas the proportion with moderate injuries increased from 19% to 37%. Adjusting for other risk factors, in-hospital deaths were higher for injuries because of motor vehicle crashes than those because of falls. In-hospital death rates were stable for patients with moderate or severe injuries, but increased over time among those whose injuries were classified as mild, suggesting a trend toward more serious injury within the "mild" classification.
Hospitalizations for TBI involve fewer mild injuries over time and are highest in the oldest segment of the population.