Wagner and Colleagues Publish TBI, Health Care Utilization, and Rehabilitation Outcome Studies in 2021

Amy Wagner, MD, professor of Physical Medicine & Rehabilitation and director of the Brain Injury Fellowship at the University of Pittsburgh, collaborated with colleagues across the country and world to publish two promising recent studies. “Acute Cortisol Profile Associations with Cognitive Impairment After Severe Traumatic Brain Injury” published in Neurorehabilitation and Neural Repair, while “Effects of an Acute Care Brain Injury Medicine Continuity Consultation Service on Health Care Utilization and Rehabilitation Outcomes” published in PM&R. The following include brief overviews of the studies and recognize contributing colleagues.

Cognitive Impairment After Severe Traumatic Brain Injury 

Cognitive impairments commonly occur after traumatic brain injury (TBI) and affect daily functioning. Cortisol levels, which are elevated during acute hospitalization for most individuals after severe TBI, can influence cognition, but this association has not been studied previously in TBI. The research team hypothesized that serum and cerebral spinal fluid (CSF) cortisol trajectories over days 0–5 post-injury are associated with cognition 6-month post-injury.

They examined 94 participants with severe TBI, collected acute serum and/or CSF samples over days 0–5 post-injury, and compared cortisol levels to those in 17 healthy controls. N = 88 participants had serum, and n = 84 had CSF samples available for cortisol measurement and had neuropsychological testing 6 months post-injury. Group based trajectory analysis (TRAJ) was used to generate temporal serum and CSF cortisol profiles which were examined for associations with neuropsychological performance. They used linear regression to examine relationships between cortisol TRAJ groups and both overall and domain-specific cognition.

TRAJ analysis identified a high group and a decliner group for serum and a high group and low group for CSF cortisol. Multivariable analysis showed serum cortisol TRAJ group was associated with overall cognitive composites scores (P = .024) and with executive function (P = .039) and verbal fluency (P = .029) domain scores. CSF cortisol TRAJ group was associated with overall cognitive composite scores (P = .021) and domain scores for executive function (P = .041), verbal fluency (P = .031), and attention (P = .034). The team concluded that high acute cortisol trajectories are associated with poorer cognition 6 months post-TBI.

View the full study.

Other Contributors

David J. Barton
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA

Raj G. Kumar
Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA

Alexandria A. Schuster
Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA

Shannon B. Juengst
Department of Applied Clinical Research, University of Texas Southwestern, Dallas, TX, USA

Byung-Mo Oh
Department of Rehabilitation Medicine, Seoul National University, Seoul, KR

Acute Care Brain Injury Medicine Continuity Consultation Service 

Although general physiatry acute-care consultation services are commonplace and improve length of stay (LOS), the benefits of a subspecialty physiatric continuity consultation service targeting patients with severe brain injury have not been reported. The research team’s primary objective was to characterize patient care recommendations from a Brain Injury Medicine (BIM) Continuity Consult Service, and to investigate the effects on acute-care LOS relative to brain injury patients receiving General Physical Medicine & Rehabilitation (PM&R) Consult Services. Their secondary objectives were to examine inpatient rehabilitation (IPR) health care utilization metrics and costs between groups and evaluate clinical improvements during IPR and discharge disposition.

Despite no major demographic or clinical group differences, the BIM Consult Service had more patient comorbidities than General PM&R Consult Service (17.5±5.3 versus 16±5.1;P = .04). BIM Consult Service patients spent fewer days in acute care (30±11.8 versus 36±22.8; P = .008), and early BIM consult (≤7 days after admission) was associated with shorter acute-care LOS (P < .002). IPR LOS was similar between groups when considering unplanned transfers. Unplanned transfers among General PM&R Consult Service patients occurred twice as frequently as in BIM Consult Service patients; average readmission costs were $2778 per patient on the BIM Consult Service and $6702 per patient on the General PM&R Consult Service. More BIM Consult Service (85.7%) than General PM&R Consult Service (27.3%) patients emerged from disorders of consciousness during IPR (P = .02).

The team concluded that BIM Continuity Consultation Services were associated with shorter acute-care LOS, fewer unplanned acute-care transfers, and an increased likelihood of emerging from a minimally conscious state during IPR.

View the full study.

Other Contributors

Justin L. Weppner
Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia, USA

Mark A. Linsenmeyer
Department of Physical Medicine and Rehabilitation, Sunnyview Rehabilitation Hospital, Schenectady, New York, USA