Traumatic Brain Injury: Reducing Disparities From the ED Through Rehab

Désirée Lie, MD, MSEd


April 26, 2010


Injuries are an important cause of death and disability,[2,3] and the third leading cause of healthcare disparities in the United States.[4,5,6] In particular, traumatic brain injury (TBI) is a major source of disability that affects over 1 million Americans yearly.[7] Each year, 50,000 people die from TBI and 85,000 suffer long-term disabilities.[8] After acute care for injuries, most patients require rehabilitation services to achieve optimal functional status to re-integrate into their previous roles in the family and society, and disparities in access and response to rehabilitation are another potential source of disparate outcomes of TBI.

A retrospective database study using the National Trauma Data Bank database suggested no mortality differences according to ethnic origin for injuries associated with gunshot wounds or motor vehicle crashes, with hypotension and other physiologic factors indicated by the injury severity score playing a more significant role in predicting outcome than racial differences.[9] However, there were, however, differences in discharge disposition, with blacks and Hispanics being less likely to be discharged directly home compared with whites (odds ratio [OR], 0.83 for blacks; 0.53 for Hispanics).

In another study using the same database, blacks and Hispanics were less likely to be insured and more likely to sustain penetrating trauma compared with white patients, and insurance status was a stronger predictor of mortality outcome than race, with insured patients having a lower crude mortality rate compared with uninsured patients (4.4% vs 8.6%, P = .05).[10]

A recent review of data from the Healthcare Cost and Utilization Project also found that ethnic disparities existed in adults aged 18 to 64 with a primary diagnosis of injury presenting to the emergency department.[11] The study compared outcomes among whites, blacks, and Asians and found black-white mortality disparities for mild to moderately injured patients (OR 1.40) and Asian-white disparities among severely injured patients (OR 1.39). Black and Asians showed higher mortality overall than white patients in this study, raising questions about access to care for serious injuries for the 2 groups.

A diverse level I trauma center, examining data from 2001 to 2004, found a higher mortality for Asians compared with whites (OR 1.38) after adjustment for confounders including injury severity score for acute care after TBI.[12] However, the degree of short-term disability was not significantly different between Asians and whites. In the same study, mortality was higher among blacks but Hispanics showed no differences compared with whites.

After mild TBI, racial disparities were found in 1 study to affect processes of care.[13] Compared with whites, Hispanics were more likely to receive a nasogastric tube (OR, 6.36); nonwhites were more likely to receive emergency department care by a resident rather than an attending (OR, 3.09), and less likely to be sent back to the referring physician after discharge (OR, 0.47).

An estimated 5.3 million Americans live with permanent disability related to TBI [8,14] and access to care and rehabilitation after TBI can determine degree of social reintegration.[15] For example, a case series found that 1 year after TBI, there is a high rate of unemployment and use of public assistance.[16] Difficulty with psychosocial adjustment arising from problems with anxiety, depression, fatigue and alcohol abuse has been shown as long as10 years after TBI.[17,18,19]

A retrospective analysis of patients from the National Trauma Data Bank (n = 58,729) found that even after adjustment for severity of TBI and insurance status, minority groups consisting of blacks and Hispanics were 15% less likely to be placed in rehabilitation after acute TBI, raising questions about the perceived efficacy of rehabilitation for some subgroups.[20] The researchers suggested that differential access to rehabilitation placement after acute injury likely had multifactorial causes that included:

  • Cost;

  • Travel distance;

  • Inaccurate assessment of patients;

  • Language and cultural barriers; and

  • Discrimination against minorities.

Community Outcomes

Community outcomes are similarly poorer for minorities after TBI. In 1 study, blacks with moderate to severe TBI were shown to lose more income than whites at 1 year post-injury.[21] In another study of 1083 adults, 1 year following TBI , after adjustment for premorbid employment, race was found to be a significant predictor of productivity, with blacks 2.8 times more likely to be nonproductive than whites; and minorities overall 2 times more likely to be nonproductive.[22] Similarly, a retrospective analysis of the national US Traumatic Brain Injury Model Systems Database that included 16 comprehensive TBI rehabilitation programs found that minorities (Hispanics, blacks, Asians, and American Indians) were 2.17 times more likely to be unemployed at 1 year after TBI after accounting for marital status, injury cause, age, and pre-injury status.[23] Over 1, 2, and 5 years after TBI, a longitudinal study comparing blacks and whites found that both short- and long-term employment was less likely for blacks than whites after accounting for injury severity and rehabilitation factors.[24] The investigators suggested that more culturally effective strategies were needed to reduce the disparate employment outcomes. Black-white differences in TBI outcomes for return to school and other functional, as well as clinical, outcomes have also been documented in children.[25]


In summary, epidemiologic studies on TBI in the United States, largely using databases, suggest racial and ethnic disparities in outcomes of care from the emergency department to rehabilitation centers that are not accounted for solely by socioeconomic and access factors. There is variability in the pattern of disparities that likely reflects local and community factors. While genotype differences may account for some of the physiologic differences in response to the treatment of traumatic injury,[26] it is likely that a multifaceted approach is needed to reduce the observed disparities. Potential sources of the disparities need to be examined and addressed. These include:

  • Access differences;

  • Possible workup biases;

  • Treatment biases; and

  • Failure to provide culturally responsive treatment strategies, including language access to patients in the emergency department or in rehabilitation services.

Patients with TBI have a chronic condition that requires long-term care. Strategies that address both systems and provider are more likely to succeed than a monolithic approach. Having a primary care home for such patients will undoubtedly improve long-term outcomes of care.[27]


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