Understanding outcomes based on the post-acute hospitalization pathways followed by persons with traumatic brain injury

PRIMARY OBJECTIVES: To identify the factors that determine the pathways of care people with traumatic brain injury (TBI) follow after acute care discharge, and to identify differences in outcome based on those pathways. RESEARCH DESIGN: Telephone survey of a statewide, population-based sample of persons surviving through acute hospitalization for TBI. METHODS AND PROCEDURES: Included were 1059 individuals who: (a) were discharged from acute care in 1996 and 1997; (b) were eligible for inclusion in the statewide, population-based TBI follow-up system, (c) had either a severe TBI or were among a 20% random sample with milder injuries, and (d) consented to participate in a 1-year post-injury follow-up survey. The survey included administration of the Functional Independence Measure (FIM), the Craig Handicap Assessment and Reporting Technique (CHART), the Alertness Behaviour Sub-scale of the Sickness Impact Profile (SIP), and the Health Status Questionnaire (HSQ-12). Medical records for all participants were abstracted for injury severity, pre-injury history (aetiologic and demographic) and discharge disposition data. Data were weighted to represent the population from which the sample was derived prior to analyses. MAIN OUTCOMES AND RESULTS: Almost 2/3 of TBI survivors in this population-based sample received no additional services following discharge from the acute care hospital. Six post-acute-hospitalization pathways were identified based on combinations of inpatient rehabilitation, community-based services and long-term care (LTC). In each category--except for the one involving a discharge directly from acute care to home--people with the most severe TBIs were disproportionately over-represented. Older people and people whose care was funded by government payers were over-represented in both care pathways involving LTC, while members of minority groups were under represented. Those who went to LTC had the poorest outcomes, but even those completing rehabilitation had relatively poor outcomes compared with those discharged directly to home. CONCLUSIONS: Of concern are the relatively large numbers of people receiving no rehabilitation and other services in all severity categories. Those in LTC--typically older and government funded people--reported the poorest outcomes. Unanswered questions remain relating to the poor perceived quality of life reported by those completing rehabilitation programmes. Further study is also needed to more fully understand the affects of such characteristics as gender, minority status, employment and funding sources on the care pathway that is followed.