Outcomes in nursing home patients with traumatic brain injury

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Abstract

Background:

Traumatic brain injury is a leading cause of death and disability in the United States. In survivors, traumatic brain injury remains a leading contributor to long-term disability and results in many patients being admitted to skilled nursing facilities for postacute care. Despite this very large population of traumatic brain injury patients, very little is known about the long-term outcomes of traumatic brain injury survivors, including rates of discharge to home or risk of death in long-term nursing facilities. We hypothesized that patient demographics and functional status influence outcomes of patients with traumatic brain injury admitted to skilled nursing facilities.

Methods:

We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries aged 65 and older discharged alive and directly from hospital to a skilled nursing facility between 2011 and 2014 using the prospectively maintained Federal Minimum Data Set combined with Medicare claims data and the Centers for Medicare and Medicaid Services Vital Status files. Records were reviewed for demographic and clinical characteristics at admission to the skilled nursing facility, including age, sex, cognitive function, ability to communicate, and motor function. Activities of daily living were reassessed at discharge to calculate functional improvement. We used robust Poisson regression with skilled nursing facility fixed effects to calculate relative risks and 99% confidence intervals for mortality and functional improvement associated with the demographic and clinical characteristics present at admission. Linear regression was used to calculate adjusted mean duration of stay.

Results:

Overall, 87,292 Medicare fee-for-service beneficiaries with traumatic brain injury were admitted to skilled nursing facilities. The mean age was 84 years, with 74% of patients older than age 80. Generally, older age, male sex, and poor cognitive or functional status at admission to a skilled nursing facility were associated with increased risk for poorer outcomes. Older patients (age ≥80 years) with traumatic brain injury had a 1.5 times greater risk of death within 30 days of admission compared with adults younger than 80 years (relative risk = 1.49, 99% confidence interval = 1.36, 1.64). Women were 37% less likely to die than men were (relative risk = 0.63, 99% confidence interval = 0.59, 0.68). The risk of death was greater for patients with poor cognitive function (relative risk = 2.55, 99% confidence interval = 2.32, 2.77), substantial motor impairment (relative risk = 2.44, 99% confidence interval = 2.16, 2.77), and patients with impairment in communication (relative risk = 2.58, 99% confidence interval = 2.32, 2.86) compared with those without the respective deficits. One year after admission, these risk factors continued to confer excess risk for mortality. Duration of stay was somewhat greater for older patients (30.1 compared with 27.5 average days) and patients with cognitive impairment (31.7 vs 27.5 average days). At discharge, patients with cognitive impairment (relative risk = 0.86, 99% confidence interval = 0.83, 0.88) and impairment in the ability to communicate (relative risk = 0.67, 99% confidence interval = 0.54, 0.82) were less likely to improve in physical function.

Conclusion:

Our results suggest that among patients with traumatic brain injury admitted to skilled nursing facilities, the likelihood of adverse outcomes varies significantly by key demographic and clinical characteristics. These findings may facilitate setting expectations among patients and families as well as providers when these patients are admitted to skilled nursing facilities for rehabilitation after their acute episode.

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