Chronic Diseases in Canada

Discharge against medical advice after traumatic brain injury: is intentional injury a predictor?

Kim H. (1); Colantonio A. (2); Bayley M. (2); Dawson D. (3)

Background/Purpose/Objectives: Discharges against medical advice (DAMA) are consistently reported as causing worse functional outcomes and frequent hospital readmissions. Our study aims to develop a risk profile of DAMA patients with traumatic brain injury (TBI), to examine factors associated with DAMA occurrence and to examine whether intentional injury is a significant predictor of DAMA.

Study design/Methods: We conducted a retrospective cohort study using hospital discharge data from the Minimal Data Set (MDS) of the Ontario Trauma Registry (OTR) for the years 1993/94 and 2000/01. The MDS review yielded 15 684 cases of TBI; 446 (2.84%) had recorded DAMA events.

Results: DAMA is significantly greater in those with intentional TBI compared to unintentional TBI. Patients with intentional injuries are two times more likely to leave hospital against medical advice than those with unintentional injuries controlling for other factors. Younger ages between 25–54 years and history of alcohol/drug abuse are also significantly associated with DAMA.

Conclusions: TBI patients who leave hospital against medical advice are a high-risk population. Intentional injury is an important independent factor to consider when modelling DAMA studies. Early identification of patients with intentional TBI could allow implementation of better preventative strategies, thus improving health outcomes and enhancing healthcare delivery.

Rehabilitation outcomes after intentional traumatic brain injury: functional changes and discharge destinations

Kim H. (1); Colantonio A. (2); Bayley M. (2); Dawson D. (3)

Background/Purpose/Objectives: Traumatic brain injury (TBI) due to violence is a major public health issue; a recent report by the Canadian Institute for Health Information (CIHI) indicates that intentional TBI is increasing among young adults. This study aims to investigate functional changes and discharge destinations of intentional TBI patients compared to unintentional TBI patients.

Study design/Methods: In this prospective cohort study, we used population-based acute care and inpatient rehabilitation records, the Discharge Abstract Dataset (DAD) and the National Rehabilitation Reporting System (NRS) from the CIHI. We examined absolute and relative functional gains in motor and cognitive subscales and discharge destinations as rehabilitation outcome measures.

Results: People with intentional TBI have significantly lower absolute gains in motor functions and relative gains in cognitive functions in univariate analyses at discharge. Intentional TBI is also associated with lower relative gains in cognitive functions, while controlling for age, gender, alcohol/drug abuse history and other demographic and clinical variables. People with intentional TBI are less likely to be discharged home, controlling for other independent variables.

Conclusions: People with intentional TBI are a distinct population in the rehabilitation setting in Canada. During in-patient rehabilitation, focusing on effective changes in cognitive functions would be more applicable to this population. Different discharge destinations would also imply that more careful discharge planning should be developed.

Author References

1. Rehabilitation Science Sector, University of Toronto, Toronto, Ontario, Canada
2. Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada
3. Kunin-Lunenfeld Applied Research Unit, Baycrest, Toronto, Ontario, Canada