3.1. Cohort Selection
The number of adult incident TBI cases from 2010/11-2017/18 was 37,344 (Figure 1). The rehabilitation cohort included a total of 6,480 individuals; 4,748 of these were individuals with moderate-to-severe TBI.
3.2. Characteristics of Individuals with Moderate-to-Severe TBI Discharged to Rehabilitation within 365 Days in Ontario
There were 4,748 individuals with moderate-to-severe TBI who were discharged to rehabilitation within 365 days from 2010/2011 to 2017/2018 (Table S1). The mean age was 64.98 years (±20.81) with significant differences reported across time (P > 0.001). 18.8% were between 16 and 45 years old, 22.0% were between 46 and 64 years old, 31.3% were between 65 and 80 years old, and 27.9% were over the age of 81. Mean age increased by fiscal year and age is significantly different across at least two fiscal year groups (P = 0.003). Most individuals with moderate-to-severe TBI were male (65.6%). The most common cause of injury was related to a fall (61.7%), with significant differences reported across time (P < .001).
The mean acute care LOS was 15.82 days (±16.93), with significant differences reported across time (P < 0.001). Mean LOS of ALC was 4.47 days (±11.66) with significant differences reported across time (P = 0.009). 13.9% had the presence of a mental health condition at the time of TBI hospitalization. The mean total LOS prior to rehabilitation/acute care discharge was 20.29 days (±22.78) with a significant difference over time (P < 0.001). In terms of acute care discharge disposition, 72.1% were discharged directly to rehabilitation (specialized or general), 13.2% were discharged to another acute care facility, 11.1% were discharged home/signed out, and 3.3% were discharged to a long-term care facility. Figure 2 illustrates the discharge pathways of individuals with TBI following their initial hospitalization from our data. Discharge disposition showed significant differences across at least two fiscal year groups (P = 0.004). The mean wait time to rehabilitation was 37.3 days (±52.5). The mean LOS at rehabilitation was 33.5 days (±34.2) with a significant difference over time (P < 0.001). In terms of discharge disposition from rehabilitation, 38.8% were discharged home with services while 30.0% were discharged home without services. Just over 7% were discharged to another acute care facility after rehabilitation. Approximately 10% had more than one rehabilitation stay within 365 days (significant change over time, P = 0.01). Overall, the average wait time to rehabilitation from the date of first admission to hospital for TBI (i.e., within the same episode of care) was 37.26 days (±52.53) (significant difference over time, P < 0.011).
The mean admission FIM was 76.1 (±23.2) with significant differences across time (P < 0.001), the mean discharge FIM was 100.9 (±22.1), and the mean FIM efficiency was 0.96 (±0.98) with significant differences over time (P < 0.001). The mean change in FIM (overall) was 24.14 (±17.11) with significant differences over time (P < 0.001). The mean change in cognitive FIM was 3.3 (±4.7) with significant differences over time (P = 0.015) while the mean change in motor FIM was 20.84 (±14.95) with significant differences over time as well (P < 0.001).
3.3. Logistic Regression Model Results
3.3.1. Odds of Specialized Rehabilitation Admission
Table 1. Logistic regression for odds of specialized rehabilitation for patients with moderate or severe TBI (N=21600).
Predictors
|
Odds Ratio
|
95% Confidence Interval
|
P-value
|
Age
|
0.9873
|
0.9847
|
0.99
|
<.0001
|
Sex M (Ref=F)
|
1.2076
|
1.0673
|
1.3663
|
0.0027
|
Rurality Y (Ref=N)
|
1.2858
|
1.0966
|
1.5076
|
0.002
|
Cause (MVC) Ref=(Fall)
|
2.0751
|
1.7309
|
2.4879
|
<.0001
|
Cause (Pedestrian struck) Ref=(Fall)
|
2.6449
|
2.0718
|
3.3766
|
<.0001
|
Cause (Sport) Ref=(Fall)
|
0.1948
|
0.0269
|
1.4081
|
0.105
|
Cause (Other) Ref=(Fall)
|
1.5034
|
1.3148
|
1.7189
|
<.0001
|
Acute Care Length of Stay (LOS)
|
1.0295
|
1.0266
|
1.0324
|
<.0001
|
Repatriation (Ref=No Repatriation)
|
0.8376
|
0.7025
|
0.9988
|
0.0484
|
Nine independent variables were included in the regression model for patients with moderate or severe TBI (N = 21,600) who were admitted to specialized rehabilitation within 365 days of discharge from the index hospitalization: age, sex, rurality, cause (motor vehicle collisions (MVC), pedestrian struck, sport, other), acute care LOS, and repatriation. Results of this logistic regression model are shown in table 1. Eight of the nine variables (all except for sports as a cause for the injury) were statistically significant for the moderate-to-severe TBI cohort.
For patients with moderate-to-severe TBI, older individuals were less likely to receive specialized rehabilitation within 365 days of acute care discharge (P < 0.0001). Male patients were more likely to receive specialized rehabilitation compared to females (P = 0.0027), and individuals from rural areas were more likely to receive specialized rehabilitation compared to those from urban areas (P = 0.002). Individuals with TBI from a fall were less likely to receive specialized rehabilitation compared to individuals who sustained their TBI from MVC, pedestrian struck accidents, and all other reported causes except for sports (P < 0.0001 for all). A longer acute care LOS contributed to a greater likelihood of receiving specialized rehab (P < 0.0001), and finally, repatriation (i.e., transfer from one acute care facility to another before rehabilitation) was associated with a lower likelihood of receiving specialized rehabilitation for individuals with moderate-to-severe TBI (P = 0.0484).
3.3.2. Odds of Repatriation (Discharge to Acute Care from Index Hospitalization)
Table 2. Logistic regression for odds of repatriation among patients with moderate or severe TBI (N=25095).
Predictors
|
Odds Ratio
|
95% Confidence
Interval
|
P-value
|
Age
|
1.0082
|
1.006
|
1.0104
|
<.0001
|
Sex M (Ref=F)
|
1.2457
|
1.1432
|
1.3574
|
<.0001
|
Rurality Y (Ref=N)
|
1.8308
|
1.6416
|
2.0418
|
<.0001
|
Cause (MCV) Ref=(Fall)
|
1.2408
|
1.0605
|
1.4518
|
0.0071
|
Cause (Pedestrian struck) Ref=(Fall)
|
1.3074
|
1.0365
|
1.6491
|
0.0236
|
Cause (Sport) Ref=(Fall)
|
0.5008
|
0.1825
|
1.3744
|
0.1794
|
Cause (Other) Ref=(Fall)
|
1.2509
|
1.138
|
1.375
|
<.0001
|
Seven independent variables were included in the regression model for patients with moderate-to-severe TBI (N = 25,095) who were repatriated (repatriation defined as discharge to acute care from index hospitalization): age, sex, rurality, and cause (MVC, pedestrian struck, sport, other). Results of this logistic regression model are shown in table 2. Six of the seven variables were statistically significant (all except for sports as a cause of injury).
Older patients were more likely to be repatriated than younger patients, and males were more likely to be repatriated than females (P < 0.0001 for both). Individuals living in rural areas were almost two times more likely to be repatriated than urban residents (P < 0.0001). Individuals with TBI as a result of falls were less likely to be repatriated than those who had an MVC (P < 0.0071), pedestrian struck accident (P < 0.0236), or other causes of injury excluding sport injuries (P < 0.0001).
3.3.3. Characteristics of Individuals with Moderate-to-Severe TBI Receiving Specialized Rehabilitation
Table 3. Characteristics of individuals with moderate-to-severe TBI receiving specialized rehabilitation within 365 days of injury.
Characteristic
|
|
No Specialized rehabilitation within 365 days
|
Specialized rehabilitation within 365 days
|
Total
|
P-value
|
|
|
N=20109
|
N=1491
|
N=21600*
|
|
Mean age (± SD)
|
|
66.67 ± 21.32
|
56.89 ± 21.70
|
66.00 ± 21.49
|
<.001
|
Sex, N(%N)
|
F
|
7450 (37.0%)
|
414 (27.8%)
|
7864 (36.4%)
|
<.001
|
|
M
|
12659 (63.0%)
|
1077 (72.2%)
|
13736 (63.6%)
|
|
Rurality, N(%N)
|
Missing
|
*39 - 43
|
*1 - 5
|
44 (0.2%)
|
<.001
|
|
N
|
17910 (89.1%)
|
1280 (85.8%)
|
19190 (88.8%)
|
|
|
Y
|
*2156 - 2160
|
*206 - 210
|
2366 (11.0%)
|
|
Cause of Injury, N(%N)
|
MVC
|
1480 (7.4%)
|
224 (15.0%)
|
1704 (7.9%)
|
<.001
|
|
Fall
|
12899 (64.1%)
|
619 (41.5%)
|
13518 (62.6%)
|
|
|
Other
|
5087 (25.3%)
|
551 (37.0%)
|
5638 (26.1%)
|
|
|
Pedestrian struck
|
*567 - 571
|
*92 - 96
|
663 (3.1%)
|
|
|
Sports Related
|
*72 - 76
|
*1 - 5
|
77 (0.4%)
|
|
Acute LOS, mean ± SD
|
|
8.40 ± 13.34
|
19.22 ± 17.91
|
9.14 ± 13.98
|
<.001
|
Repatriation, N(%N)
|
No
|
17873 (88.9%)
|
1326 (88.9%)
|
19199 (88.9%)
|
0.95
|
|
Yes
|
2236 (11.1%)
|
165 (11.1%)
|
2401 (11.1%)
|
|
Severity, N(%N)
|
Moderate
|
1375 (6.8%)
|
133 (8.9%)
|
1508 (7.0%)
|
0.002
|
|
Severe
|
18734 (93.2%)
|
1358 (91.1%)
|
20092 (93.0%)
|
|
*Note: patients with index date from April 1st, 2017, to March 31st, 2018, (N=3495) were excluded to allow full 365 days of follow-up for rehabilitation admission.
Table 3 compares the characteristics of individuals with moderate of severe TBI who did and did not receive specialized rehabilitation following acute care discharge. Over 90% of individuals with moderate-to-severe TBI did not receive specialized rehabilitation within 365 of their injury. Those who did not receive specialized rehabilitation were significantly older (66.7 years ± 21.3 vs. 56.9 years ± 21.7) than those who did (P < 0.001). The most common cause of injury for both groups was falls. Individuals who received specialized rehabilitation had a significantly longer mean acute care length of stay (19.2 years ± 17.9 vs. 8.4 years ± 13.3, P < 0.001). 11.1% of both groups were repatriated.
3.3.4. Characteristics of Individuals with Moderate-to-Severe TBI who were Repatriated
Table 4. Characteristics of individuals with moderate-to-severe TBI repatriated following initial hospitalization.
Characteristic
|
|
Not repatriated
|
Repatriated
|
Total
|
P-value
|
|
|
N=22265
|
N=2830
|
N=25095
|
|
Mean age (± SD)
|
|
66.05 ± 21.73
|
67.96 ± 19.03
|
66.27 ± 21.45
|
<.001
|
Sex, N(%N)
|
F
|
8215 (36.9%)
|
927 (32.8%)
|
9142 (36.4%)
|
<.001
|
|
M
|
14050 (63.1%)
|
1,903 (67.2%)
|
15953 (63.6%)
|
|
Rural, N(%N)
|
Missing
|
48 (0.2%)
|
10 (0.4%)
|
58 (0.2%)
|
<.001
|
|
N
|
19989 (89.8%)
|
2348 (83.0%)
|
22337 (89.0%)
|
|
|
Y
|
2228 (10.0%)
|
472 (16.7%)
|
2700 (10.8%)
|
|
Cause of injury, N(%N)
|
MVC
|
1745 (7.8%)
|
232 (8.2%)
|
1977 (7.9%)
|
0.006
|
|
Fall
|
13840 (62.2%)
|
1,677 (59.3%)
|
15517 (61.8%)
|
|
|
Other
|
5930 (26.6%)
|
829 (29.3%)
|
6759 (26.9%)
|
|
|
Pedestrian struck
|
*665 - 669
|
*87 - 91
|
756 (3.0%)
|
|
|
Sports Related
|
*81 - 85
|
*1 - 5
|
86 (0.3%)
|
|
Severity, N(%N)
|
Moderate
|
1585 (7.1%)
|
151 (5.3%)
|
1736 (6.9%)
|
<.001
|
|
Severe
|
20680 (92.9%)
|
2679 (94.7%)
|
23359 (93.1%)
|
|
Table 4 compares the characteristics of individuals with moderate-to-severe TBI who were or were not repatriated following acute care discharge. On average, those who were repatriated following initial hospitalization were older than those who were not (67.96 years ± 19.03 vs 66.1 years ± 21.7; P < 0.001). Almost 17% of repatriated individuals were residents of rural areas, while only 10% of those not repatriated were residents of rural areas. A higher proportion of repatriated patients had sustained their injury from causes other than MVC, falls, pedestrian struck accidents, or sports, when compared to non-repatriated patients (29.3% vs 26.6%).