Traumatic Brain Injury and Health Disparities among BIPOC Communities

Alaina S. Davis

Purpose: The aim of this tutorial is to highlight racial bias and challenges for Black adult athletes' cognitive-communication disorders associated with sports-related concussion (SRC). The author discusses racial bias in SRC literature and research and cultural differences in the cognitive and communication styles of Black athletes that lead to bias. The tutorial highlights challenges placed on the Black athletes when culturally responsive practices are not used in research and clinical practice. Finally, speech-language pathology clinicians and researchers are provided with practical solutions to decrease racial barriers in SRC research and clinical practice.

Conclusion: Challenges for Black adult athletes with SRC can be overcome when speech-language pathology clinicians and researchers increase their awareness of what causes racial health disparities, eliminate beliefs in stereotypes centered around the cognitive and communication styles of Black adults, and engage in culturally responsive practices that promote equity and inclusion.

Justin Maldonado, Jason H. Huang, Ed W. Childs, and Binu Tharakan.

Purpose: Traumatic brain injury (TBI) is a major cause of death and disability in the United States, exacting a debilitating physical, social, and financial strain. Therefore, it is crucial to examine the impact of TBI on medically underserved communities in the U.S. The purpose of the current study was to review the literature on TBI for evidence of racial/ethnic differences in the U.S.

Results: Significant racial/ethnic disparities in TBI outcome and several notable differences in other TBI variables were found. American Indian/Alaska Natives have the highest rate and number of TBI-related deaths compared with all other racial/ethnic groups; Blacks/African Americans are significantly more likely to incur a TBI from violence when compared with Non-Hispanic Whites; and minorities are significantly more likely to have worse functional outcome compared with Non-Hispanic Whites, particularly among measures of community integration. We were unable to identify any studies that looked directly at underlying racial/ethnic biological variations associated with different TBI outcomes. In the absence of studies on racial/ethnic differences in TBI pathobiology, taking an indirect approach, we looked for studies examining racial/ethnic differences in oxidative stress and inflammation outside the scope of TBI as they are known to heavily influence TBI pathobiology. The literature indicates that Blacks/African Americans have greater inflammation and oxidative stress compared with Non-Hispanic Whites.

Conclusions: We propose that future studies investigate the possibility of racial/ethnic differences in inflammation and oxidative stress within the context of TBI to determine whether there is any relationship or impact on TBI outcome.

Warren KL, García JJ.

Background: Persons of color have a higher incidence of traumatic brain injury (TBI) and experience disparities in the quality and quantity of interventions received, discharge disposition, functional outcomes, and mortality rate post TBI.

Objective: To examine racial/ethnic differences in rehabilitation outcomes for patients with TBI.

Design: Multiyear (2005-2016) and retrospective cohort using secondary data analysis from inpatient rehabilitation facilities (IRFs) across the United States.

Main outcome measures: Inpatient rehabilitation functional outcomes and discharge disposition.

Results: Participants were 41,847 non-Hispanic Whites (NHWs), Hispanics, non-Hispanic Asians (NHAs), and non-Hispanic Blacks (NHBs) aged 18-107 years. NHWs were used as the reference group. NHBs had the longest length of stay (17.65 ± 14.96). At admission, NHB, Hispanic, and NHA races/ethnicities were significantly associated with 1-3 point lower motor, cognitive, and total Functional Independence Measure (FIM) scores. NHB race was significantly associated with less than 1-point lower cognitive, motor, and total efficiency FIM scores. At discharge, NHB race was significantly associated with 1-2 point lower motor, cognitive, and total FIM scores; Hispanics and NHA race were associated with less than 1-point lower cognitive FIM scores. Compared to NHWs, Hispanic ethnicity was associated with greater odds of a discharge to home (odds ratio = 1.16, 95% confidence interval = 1.06-1.27).

Conclusion: Contrary to established literature on functionality differences 1 year post TBI, the current study found racial/ethnic differences in functional outcomes during inpatient rehabilitation. These findings suggest a need for cultural competence/sensitivity in the care of racial/ethnic persons and centering potential contributing factors for racial/ethnic differences in TBI rehabilitation outcomes.

Saadi A, Bannon S, Watson E, Vranceanu AM.

Results: Our narrative review of 39 articles elucidated numerous ways in which racial and ethnic disparities span the TBI continuum of care, including acute care and diagnosis, post-TBI recovery and adjustment, and long-term outcomes.

Conclusions: Understanding racial and ethnic disparities is a first step in ensuring equitable care for all individuals with TBI, including raising awareness among clinicians and guiding the development of tailored interventions for racial and ethnic minority populations.

Richie EA, Nugent JG and Raslan AM

Purpose: The health disparities which drive inequities in health outcomes have long plagued our already worn healthcare system and are often dismissed as being a result of social determinants of health. Herein, we explore the nature of these inequities by comparing outcomes for racial and ethnic minorities patients suffering from traumatic brain injury (TBI).

Methods: We retrospectively reviewed all patients enrolled in the Trauma One Database at the Oregon Health & Science University Hospital from 2006 to October 2017 with an abbreviated injury scale (AIS) for the head or neck >2. Racial and ethnic minority patients were defined as non-White or Hispanic.

Results: A total of 6,352 patients were included in our analysis with 1,504 in the racial and ethnic minority cohort vs. 4,848 in the non-minority cohort. A propensity score (PS) model was generated to account for differences in baseline characteristics between these cohorts to generate 1,500 matched pairs. The adjusted hazard ratio for in-hospital mortality for minority patients was 2.21 [95% Confidence Interval (CI) 1.43–3.41, p < 0.001] using injury type, probability of survival, and operative status as covariates.

Conclusions: Overall, this study is the first to specifically look at racial and ethnic disparities in the field of neurosurgical trauma. This research has demonstrated significant inequities in the mortality of TBI patients based on race and ethnicity and indicates a substantive need to reshape the current healthcare system and advocate for safer and more supportive pre-hospital social systems to prevent these life-threatening sequelae.

Pretz C, Kowalski RG, Cuthbert JP, Whiteneck GG, Miller AC, Ketchum JM, Dams-OʼConnor K.

Purpose: Return to work and school following traumatic brain injury (TBI) is an outcome of central importance both to TBI survivors and to society. The current study estimates the probability of returning to productivity over 5 years following moderate to severe brain injury.

Results: Baseline variables, age of injury, race, level of education and occupational category at the time of injury, disability rating at hospital discharge, substance abuse status, and rehabilitation length of stay, are significantly associated with probability of return to productivity. Individual-level productivity trajectories generally indicate that the probability of returning to productivity increases over time.

Brenner EK, Grossner EC, Johnson BN, Bernier RA, Soto J, Hillary FG.

Purpose: This study has three goals: to determine whether there is a higher rate of traumatic brain injury (TBI) for people of color (POC), whether TBI studies report racial/ethnic demographics, and whether there is a discrepancy in discharge destinations between Whites and POC. We examined whether 1) a higher percentage of POC would sustain head injuries than expected, 2) the majority of TBI studies examined (>50%) would not include racial/ethnic demographics, and 3) Whites would be discharged to further treatment over POC.

Results: Results demonstrated that Blacks sustain more TBIs than would be expected (p < .05), the majority of scientific studies (78%) do not report racial/ethnic demographic information, and Whites are discharged to further care more often than POC.

Conclusions: These findings highlight differences in incidence and treatment of TBI between White individuals and POC, raising important considerations for providers and researchers.

Dams-OʼConnor K, Ketchum JM, Cuthbert JP, Corrigan JD, Hammond FM, Haarbauer-Krupa J, Kowalski RG, Miller AC.

Purpose: To describe trajectories of functioning up to 5 years after traumatic brain injury (TBI) that required inpatient rehabilitation in the United States using individual growth curve models conditioned on factors associated with variability in functioning and independence over time. 4642 individuals >16 years old with TBI followed for 5 years after inpatient rehab

Results: Factors such as older age, non-White race, lower preinjury productivity, public payer source, longer length of inpatient rehabilitation stay, and lower discharge functional status were found to negatively impact trajectories of change over time.

Zarshenas S, Colantonio A, Alavinia SM, Jaglal S, Tam L, Cullen N.

Objective: To systematically review studies on clinical and nonclinical predictors of discharge destination from acute care in patients with traumatic brain injury.

Methods: The search was conducted using 7 databases up to December 2016. A systematic review and in-depth quality synthesis were conducted on eligible articles that met the inclusion criteria.

Results: The search yielded 8503 articles of which 18 studies met the inclusion criteria. This study demonstrated that a larger proportion of patients with traumatic brain injury were discharged home. The main predictors of discharge to a setting with rehabilitation services versus home included increasing age, white and non-Hispanic race/ethnicity, having insurance coverage, greater severity of the injury, and longer acute care length of stay. Age was the only consistent factor that was negatively associated with discharge to inpatient rehabilitation facilities versus other institutions.

Conclusion: Results of this study support healthcare providers in providing consultation to patients about the expected next level of care while considering barriers that may be helpful in effective discharge planning, decreasing length of stay and saving resources. These findings also suggest the need for further studies with a stronger methodology on the contribution of patients and families/caregivers to distinguish the predictors of discharge to dedicated rehabilitation facilities.

Haines KL, Nguyen BP, Vatsaas C, Alger A, Brooks K, Agarwal SK.

Purpose: Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI.

Methods: This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS).

Results: We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5.

Conclusions: Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.

Gao S, Kumar RG, Wisniewski SR, Fabio A.

Purpose: To characterize racial/ethnic and insurance disparities in the utilization of healthcare services among US adults with traumatic brain injury (TBI).

Results: Lack of insurance was significantly associated with decreased use of inhospital and posthospital healthcare services among patients with TBI. However, mixed results were reported for the associations between insurance types and healthcare utilization. The majority of studies reported that racial/ethnic minorities were less likely to use inhospital and posthospital healthcare services, while some studies did not indicate any significant relation between race/ethnicity and healthcare utilization among patients with TBI.

Conclusions: This review provides evidence of a relation between insurance status and healthcare utilization among US adults with TBI. Insurance status may also account for some portion of the relation between race/ethnicity and healthcare utilization.

Hall WJ, Chapman MV, Lee KM, et al.

Methods: We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings.

Results: Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient-provider interactions and health outcomes than treatment processes.

Conclusions: Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color.