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Understanding the factors associated with elevated risks and adverse consequences of traumatic brain injury (TBI) is an integral part of developing preventive measures for TBI. Brain injury outcomes differ based on one's sex (biological characteristics) and gender (social characteristics reflecting norms and relationships), however, whether it is sex or gender that drives differences in early (30-day) mortality and discharge location post-TBI is not well understood. In the absence of a gender variable in existing data, we developed a method for "measuring gender" in 276,812 residents of Ontario, Canada who entered the emergency department and acute care hospitals with a TBI diagnostic code between April 1st, 2002, and March 31st, 2020. We applied logistic regression to analyse differences in diagnostic codes between the sexes and to derive a gender score that reflected social dimensions. We used the derived gender score along with a sex variable to demonstrate how it can be used to separate the relationship between sex, gender and TBI outcomes after severe TBI. Sex had a significant effect on early mortality after severe TBI with a rate ratio (95% confidence interval (CI)) of 1.54 (1.24–1.91). Gender had a more significant effect than sex on discharge location. A person expressing more "woman-like" characteristics had lower odds of being discharged to rehabilitation versus home with odds ratio (95% CI) of 0.54 (0.32–0.88). The method we propose offers an opportunity to measure a gender effect independently of sex on TBI outcomes. [ABSTRACT FROM AUTHOR]

This study identified the social determinants of health (SDoH) associated with psychological distress in adults with and without a self-reported history of traumatic brain injury (TBI), stratified by sex. Data from the 2014–2017 cycles of the Centre for Addiction and Mental Health Monitor Survey, a representative survey of adults ≥18 years in Ontario, Canada, were analyzed (N = 7,214). The six-item version of the Kessler Psychological Distress Scale was used to determine moderate to severe psychological distress. Self-reported lifetime TBI was defined as a head injury resulting in a loss of consciousness for ≥5 minutes or at least one-night stay in the hospital (16.4%). Among individuals reporting a history of TBI, 30.2% of males and 40.1% of females reported psychological distress (p = 0.0109). Among individuals who did not report a history of TBI, 17.9% of males and 23.5% of females reported psychological distress (p<0.0001). Multivariable logistic regression analyses showed that the SDoH significantly associated with elevated psychological distress were similar between individuals with and without a history of TBI. This included unemployment, student, or 'other' employment status among both males and females; income below the provincial median and age 65+ among males; and rural residence among females. This study highlighted opportunities for targeted population-level interventions, namely accessible and affordable mental health supports for individuals with lower income. Notably, this study presented evidence suggesting adaptations to existing services to accommodate challenges associated with TBI should be explored, given the finite and competing demands for mental health care and resources. [ABSTRACT FROM AUTHOR]

Background: The interplay of host, agent, and environment implicated in traumatic brain injury (TBI) events is difficult to account for in hypothesis-driven research. Data-driven analysis of injury data can enable insight into injury events in novel ways. This research dissected complex and multidimensional data at the time of the TBI event by exploiting data mining and information visualization methods.Methods: We drew upon population-based decade-long health administrative data collected through the routine operation of the publicly funded health system in Ontario, Canada. We applied a computational approach to categorize health records of 235,003 patients with TBI versus the same number of reference patients without TBI, individually matched based on sex, age, place of residence, and neighbourhood income quantile. We adopted the basic concepts of the Haddon Matrix (host, agent, environment) to organize emerging factors significantly related to TBI versus non-TBI events. To explore sex differences, the data of male and female patients with TBI were plotted on heatmaps and clustered using hierarchical clustering algorithms.Results: Based on detected similarities, the computational technique yielded 34 factors on which individual TBI-event codes were loaded, allowing observation of a set of definable patterns within the host, the agent, and the environment. Differences in the patterns of host, agent and environment were found between male and female patients with TBI, which are currently not identified based on data from injury surveillance databases. The results were internally validated.Conclusions: The study outlines novel areas for research relevant to TBI and offers insight into how computational and visual techniques can be applied to advance the understanding of TBI event. Results highlight unique aspects of sex differences of the host and agent at the injury event, as well as differences in exposure to adverse social and environmental circumstances, which can be a function of gender, aiding in future studies of injury prevention and gender-transformative care. [ABSTRACT FROM AUTHOR]

Objective: To understand how pre-injury health status present five-years preceding traumatic brain injury (TBI) affects direct medical cost two years post-injury. Methods: Patients age ≥19 years in the emergency department (ED) or acute care for a TBI between April 1, 2007 and March 31, 2014 in Ontario, Canada (N = 55,669) were identified from population-based health administrative data. Forty-three factors of pre-injury health status (i.e., comorbidities and personal, social, and environmental factors) that were internally validated for the TBI population were assessed in this study. The outcome of interest was direct medical cost within two years of discharge. Sex-specific multivariable linear regressions were conducted to understand the associations between direct medical cost within two years of discharge and pre-injury health status. Results: Patients who received care in the ED (81.9% of total sample) incurred a median cost of $2,492/male patient (average $12,342/patient) and $3,508/female patient (average $65,285/patient) within two years of injury; 37 pre-injury factors were significantly associated with increased direct medical costs. Patients who first received care for their TBI in acute care (18.1%) incurred a median cost of $25,081/male patient (average $63,060/patient) and $30,277/female patient (average $65,285/patient) within two years of injury; 21 factors were significantly associated with increased direct medical costs. Among more prevalent factors, those associated with increased medical cost by at least 50% included mental health disorders, substance abuse, disorders or medical conditions frequently observed among the elderly, cardiovascular disorders, stroke and emergencies involving the brain, metabolic disorders and abdominal symptoms, conditions and symptoms of abdomen and pelvis, genitourinary disorders and disorders of prostate, and pulmonary abdominal and other emergencies. Conclusions: Direct medical costs two years post-TBI differed significantly between patients with and without adverse pre-existing health status. Interdisciplinary teams to promote early identification of pre-existing health conditions and appropriate management and integration of these conditions in TBI care across the continuum of healthcare may be opportunities to reduce direct medical costs post-injury. [ABSTRACT FROM AUTHOR]

Background: The cervical spine region can be especially vulnerable to concurrent injury in concussion, with research suggesting that females may be at greater risk due to their weaker and anatomically distinct necks. The main objective of our research was to study sex differences in the rate of neck injury comorbidity across the life span among patients with a concussion diagnosis in the emergency department (ED) setting, by cause of injury (motor vehicle collisions [MVC] and sports). Materials and Methods: All patients with a first concussion-related ED visit between fiscal years 2002/2003 and 2011/2012 (inclusive) in Ontario were identified in population-based health administrative data using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) codes. Age-dependent odds ratios of comorbid neck injury for sex were estimated using polynomial multivariable logistic regression models, adjusting for sociodemographic characteristics. Results: Females with a concussion had significantly higher odds of sustaining a comorbid neck injury between the ages of 5–49 years for all concussion-related ED visits, 15–49 years for MVC-related concussion ED visits, and 10–39 years for sports-related concussion ED visits, holding all other covariates in the model constant. Conclusions: These results support the consideration of increased screening for comorbid neck injuries, particularly for females, to allow for early intervention. Furthermore, the increased risk of comorbid neck injury in females with a concussion-related ED visit was age-dependent, with the interaction between sex and age following a nonlinear trend. As such, future studies on concussions should consider linear and nonlinear sex and age interactions. [ABSTRACT FROM AUTHOR]

Background: There is currently no active surveillance of metastatic and non-malignant brain tumours in Canada as well as data on the health service use of children and youth with brain tumours. The objective of this study was to identify pediatric primary, metastatic, benign, and unspecified brain tumours in Ontario, Canada and to describe their health service use from a population based perspective.Methods: The population based healthcare administrative databases National Ambulatory Care Reporting System and the Discharge Abstract Database were used. Patients with malignant (primary and metastatic), benign, and unspecified brain tumours in acute care between fiscal year 2003/04 and 2009/10 were identified using specified International Classification of Diseases version ten codes.Results: Between fiscal year 2003/04 and 2009/10, there were 4022 brain tumour episodes of care (18.4 per 100,000 children and youth). Malignant brain tumors had the highest rates of episodes of care (14.9 times higher than that of benign and 5.7 times higher than that of unspecified brain tumours). Compared to patients with malignant brain tumours, those with benign brain tumours spent a longer period of time in acute care (p < .05) and patients with unspecified brain tumours stayed in the intensive care units for a longer period of time (p < .0001) with a lower proportion were discharged home (p < .0001).Conclusion: Despite higher rates of malignant brain tumour episodes of care, patients with benign and unspecified brain tumours also use acute care services and post-acute services that are currently not taken into account in healthcare planning and resource allocation. Active surveillance and research of metastatic and non-malignant brain tumours that can inform the planning of healthcare services and resource allocation for this population is encouraged. [ABSTRACT FROM AUTHOR]

Data on the utilization of occupational therapy among patients with brain tumors have been limited to those with malignant tumors and small samples of patients outside North America in specialized palliative care settings. We built on this research by examining the characteristics of patients with brain tumors who received postacute occupational therapy services in Ontario, Canada, using health care administrative data. Between fiscal years 2004–2005 and 2008–2009, 3,199 patients with brain tumors received occupational therapy services in the home care setting after hospital discharge; 12.4% had benign brain tumors, 78.2% had malignant brain tumors, and 9.4% had unspecified brain tumors. However, patients with benign brain tumors were older (mean age = 63.3 yr), and a higher percentage were female (65.2%). More than 90% of patients received in-home occupational therapy services. Additional research is needed to examine the significance of these differences and to identify factors that influence access to occupational therapy services in the home care setting. [ABSTRACT FROM AUTHOR]

Video game playing has become a very popular activity among adolescents. Its impact on the mental health and well-being of players is just beginning to be explored. This paper reports on the prevalence of problematic gaming in a representative sample of 2,832 Ontario students in grades 7 to 12. The survey included questions about the school grade, family and school related problems, frequency of video game playing and video game related problems as measured by the Problem Video Game Playing scale (PVP). Most of the students (85 %) reported playing video games in the past year and 18.3 % reported playing video games daily. Slightly less then 1 in 10 of the students (9.4 %) endorsed 5 or more of the PVP items (males 15.1 %; females 3.1 %). Further research is required to delineate the concept of excessive video game playing, its relation to other addictions, and the impact on adolescents' psychosocial functioning. [ABSTRACT FROM AUTHOR]

Background: Cannabis use has been linked to anxiety and mood disorders (AMD) in clinical cases, but little research on this relationship has been reported at the epidemiological level. Objectives: We examined the relationship between self-reported frequency of cannabis use and risk for AMD in the general Ontario adult population. Methods: Data were based on the CAMH Monitor survey of Ontario adults from 2001 to 2006 ( n = 14,531). AMD was assessed with the 12-item version of the General Health Questionnaire (GHQ12). Frequency of cannabis use within the past year was grouped into five categories: No use (abstainer), less than once a month but at least once a year, less than once a week but at least once a month, less than daily but at least once a week, almost every day to more than once a day. Logistic regression analysis of AMD and cannabis use was implemented while controlling for demographics and alcohol problems. Results: AMD was most common among heavy cannabis users (used almost every day or more) (18.1%) and lowest for abstainers (8.7%). Compared to abstainers, the risk of AMD was significantly greater for infrequent cannabis users ( OR = 1.43) and heavy cannabis users ( OR = 2.04) but not for those in between. Conclusion: These data provide epidemiological evidence for a link between both light and heavy cannabis use and AMD. Scientific Significance: Recognizing the comorbidity of heavy cannabis use and AMD should facilitate improved treatment efforts. Our results also suggest the possibility that, for some individuals, AMD may occur at relatively low levels of cannabis use. [ABSTRACT FROM AUTHOR]

An increasing number of patients are able to survive traumatic brain injuries (TBIs) with advanced resuscitation. However, the role of their pre-injury health status in mortality in the following years is not known. Here, we followed 77,088 consecutive patients (59% male) who survived the TBI event in Ontario, Canada for more than a decade, and examined the relationships between their pre-injury health status and mortality rates in excess to the expected mortality calculated using sex- and age-specific life tables. There were 5792 deaths over the studied period, 3163 (6.95%) deaths in male and 2629 (8.33%) in female patients. The average excess mortality rate over the follow-up period of 14 years was 1.81 (95% confidence interval = 1.76-1.86). Analyses of follow-up time windows showed different patterns for the average excess rate of mortality following TBI, with the greatest rates observed in year one after injury. Among identified pre-injury comorbidity factors, 33 were associated with excess mortality rates. These rates were comparable between sexes. Additional analyses in the validation dataset confirmed that these findings were unlikely a result of TBI misclassification or unmeasured confounding. Thus, detection and subsequent management of pre-injury health status should be an integral component of any strategy to reduce excess mortality in TBI patients. The complexity of pre-injury comorbidity calls for integration of multidisciplinary health services to meet TBI patients' needs and prevent adverse outcomes. [ABSTRACT FROM AUTHOR]

Objective: Existing studies, in mostly male samples such as veterans and athletes, show a strong association between traumatic brain injury (TBI) and mental illness. Yet, while an understanding of mental health before pregnancy is critical for informing preconception and perinatal supports, there are no data on the prevalence of active mental illness before pregnancy in females with TBI. We examined the prevalence of active mental illness ≤2 years before pregnancy (1) in a population with TBI, and (2) in subgroups defined by sociodemographic, health, and injury-related characteristics, all compared to those without TBI., Method: This population-based cross-sectional study was completed in Ontario, Canada, from 2012 to 2020. Modified Poisson regression generated adjusted prevalence ratios (aPRs) of active mental illness ≤2 years before pregnancy in 15,585 females with TBI versus 846,686 without TBI. We then used latent class analysis to identify subgroups with TBI according to sociodemographic, health, and injury-related characteristics and subsequently compared them to females without TBI on their outcome prevalence., Results: Females with TBI had a higher prevalence of active mental illness ≤2 years before pregnancy than those without TBI (44.1% vs. 25.9%; aPR 1.46, 95% confidence interval, 1.43 to 1.49). There were 3 TBI subgroups, with Class 1 (low-income, past assault, recent TBI described as intentional and due to being struck by/against) having the highest outcome prevalence., Conclusions: Females with TBI, and especially those with a recent intentional TBI, have a high prevalence of mental illness before pregnancy. They may benefit from mental health screening and support in the post-injury, preconception, and perinatal periods., Plain Language Title: Mental illness in the 2 years before pregnancy in a population with traumatic brain injury., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Eyal Cohen reports paid membership on the Committee to Evaluate Drugs, which advises Ontario's Ministry of Health on public drug policy. Natasha Saunders receives an honorarium from the BMJ Group (Archives of Diseases in Childhood). Simone N. Vigod receives royalties from UpToDate for authorship of materials on depression and pregnancy.

Objectives: To understand how health status preceding traumatic brain injury (TBI) affects relative functional gain after inpatient rehabilitation using a data mining approach., Design: Population-based, sex-stratified, retrospective cohort study using health administrative data from Ontario, Canada (39% of the Canadian population)., Setting: Inpatient rehabilitation., Participants: Patients 14 years or older (N=5802; 63.4% male) admitted to inpatient rehabilitation within 1 year of a TBI-related acute care discharge between April 1, 2008, and March 31, 2015., Interventions: Not applicable., Main Outcome Measures: Relative functional gain (RFG) in percentage, calculated as ([discharge FIM-admission FIM]/[126-admission FIM]×100). Health status prior to TBI was identified and internally validated using a data mining approach that categorized all International Classification of Diseases, 10th revision, codes for each patient., Results: The average RFG was 52.8%±27.6% among male patients and 51.6%±27.1% among female patients. Sex-specific Bonferroni adjusted multivariable linear regressions identified 10 factors of preinjury health status related to neurology, emergency medicine, cardiology, psychiatry, geriatrics, and gastroenterology that were significantly associated with reduced RFG in FIM for male patients. Only 1 preinjury health status category, geriatrics, was significantly associated with RFG in female patients., Conclusions: Comorbid health conditions present up to 5 years preceding the TBI event were significantly associated with RFG. These findings should be considered when planning and executing interventions to maximize functional gain and to support an interdisciplinary approach. Best practices guidelines and clinical interventions for older male and female patients with TBI should be developed given the increasingly aging population with TBI., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Assault by strangulation has the potential for severe brain injury or death. The objectives of this study were to describe the profile of individuals who had strangulation-related emergency department (ED) or acute care visits, and to explore 1-year readmission outcomes among survivors., Methods: A population-based retrospective cohort study was conducted using health administrative data in Ontario, Canada. Adults aged 15 years and older who were seen in the ED or acute care with assault by strangulation between fiscal years 2002/2003 and 2016/2017 were included in the study. Bivariate analyses were conducted to compare the patient profile and subsequent readmissions within 1 year of discharge, stratified by sex., Results: A total of 586 patients were included in the study. The majority of these patients were seen in the ED (93%), predominantly female (70%), aged ≤ 39 years (68%), and of lower income quintiles of ≤ 3 (73%). Of the 579 patients who survived the initial admission, 52% had subsequent ED readmission and 21% had acute care readmission within 1 year. In sex-stratified analyses, a higher proportion of females were between 20 to 39 years (58.7% vs. 44.1%, p = 0.001), discharged home (88% vs. 81%, p < 0.001), and had ED readmission within 1 year of discharge (56% vs. 17%, p = 0.002). Males had comparatively higher 1-year acute care readmissions., Conclusion: The study shows high readmissions with sex differences among individuals with an assault by strangulation, suggesting sex-specific approach to health care practices to support the needs of this vulnerable population, thus reducing health system inefficiencies.

Objective : To identify predictors of in-hospital mortality following Hypoxic-Ischemic Brain Injury (HIBI) using the Anderson Behavioral Model. Design and Setting : Population based retrospective cohort study in Ontario, Canada with data collected between 1 April 2002 and 31 March 2017. Patients : Adult patients aged 20 years and older with HIBI-related acute care admission were identified in the health administrative data. Multivariable cox proportional hazard regression models were used to identify predisposing, need and enabling factors that predict in-hospital mortality. Results : Of the 7492 patients admitted to acute care with HIBI, the in-hospital mortality rate was 71%. The predisposing factors associated with mortality were female sex (HR, 1.16; 95% CI, 1.10-1.23) and older age (65-79 vs. 20-34: HR, 1.17; 95% CI, 1.02-1.35). The need factors associated with mortality were the presence of COPD (HR, 1.10; 95% CI, 1.02-1.17), psychiatric illness (HR, 1.13; 95% CI, 1.05-1.20) injury due to cardiac illness (HR, 1.19; 95% CI, 1.12-1.26) and longer emergency department length of stay. Having spending any time in an alternate level of care and the application of tracheotomy procedures were found to reduce mortality. Conclusions : The acute/critical care centers need to consider these findings to adopt prevention strategies targeting reduced in-hospital mortality.

Background: Acquired brain injury (ABI), which includes traumatic (TBI) and non-traumatic brain injury (nTBI), is a leading cause of death and disability worldwide. The objective of this study was to examine the trends, characteristics, cause of brain injury, and discharge destination of hospitalized older adults aged 65 years and older with an ABI diagnosis in a population with universal access to hospital care. The profile of characteristics of patients with TBI and nTBI causes of injury was also compared., Methods: A population based retrospective cohort study design with healthcare administrative databases was used. Data on acute care admissions were obtained from the Discharge Abstract Database and patients were identified using the International Classification of Diseases - Version 10 codes for Ontario, Canada from April 1, 2003 to March 31, 2010. Older adults were examined in three age groups - 65 to 74, 75 to 84, and 85+ years., Results: From 2003/04 to 2009/10, there were 14,518 episodes of acute care associated with a TBI code and 51, 233 episodes with a nTBI code. Overall, the rate of hospitalized TBI and nTBI episodes increased with older age groups. From 2007/08 to 2009/10, the percentage of patients that stayed in acute care for 12 days or more and the percentage of patients with delayed discharge from acute care increased with age. The most common cause of TBI was falls while the most common type of nTBI was brain tumours. The percentage of patients discharged to long term care and complex continuing care increased with age and the percentage discharged home decreased with age. In-hospital mortality also increased with age. Older adults with TBI and nTBI differed significantly in demographic and clinical characteristics and discharge destination from acute care., Conclusions: This study showed an increased rate of acute care admissions for both TBI and nTBI with age. It also provided additional support for falls prevention strategies to prevent injury leading to cognitive disability with costly human and economic consequences. Implications for increased numbers of people with ABI are discussed.

Alternate-level-of-care (ALC) days represent hospital beds that are taken up by patients who would more appropriately be cared for in other settings. ALC days have been found to be costly and may result in worse functional outcomes, reduced motor skills and longer lengths of stay in rehabilitation. This study examines the factors that are associated with acute care ALC days among patients with acquired brain injury (ABI). We used the Discharge Abstract Database to identify patients with ABI using International Classification of Disease-10 codes. From fiscal years 2007/08 to 2009/10, 17.5% of patients with traumatic and 14% of patients with non-traumatic brain injury had at least one ALC day. Significant predictors include having a psychiatric co-morbidity, increasing age and length of stay in acute care. These findings can inform planning for care of people with ABI in a publicly funded healthcare system.

Background: The aim of this paper is to examine factors associated with discharge destination after acquired brain injury in a publicly insured population using the Anderson Behavioral Model as a framework., Methods: We utilized a retrospective cohort design. Inpatient data from provincial acute care records from fiscal years 2003/4 to 2006/7 with a diagnostic code of traumatic brain injury (TBI) and non-traumatic brain injury (nTBI) in Ontario, Canada were obtained for the study. Using multinomial logistic regression models, we examined predisposing, need and enabling factors from inpatient records in relation to major discharge outcomes such as discharge to home, inpatient rehabilitation and other institutionalized care., Results: Multinomial logistic regression revealed that need factors were strongly correlated with discharge destinations overall. Higher scores on the Charlson Comorbidity Index were associated with discharge to other institutionalized care in the nTBI population. Length of stay and special care days were identified as markers for severity and were both strongly positively correlated with discharge to other institutionalized care and inpatient rehabilitation, compared to discharge home, in both nTBI and TBI populations. Injury by motor vehicle collisions was found to be positively correlated with discharge to inpatient rehabilitation and other institutionalized care for patients with TBI. Controlling for need factors, rural location was associated with discharge to home versus inpatient rehabilitation., Conclusions: These findings show that need factors (Charlson Comorbidity Index, length of stay, and number of special care days) are most significant in terms of discharge destination. However, there is evidence that other factors such as rural location and access to supplemental insurance (e.g., through motor vehicle insurance) may influence discharge destination outcomes as well. These findings should be considered in creating more equitable access to healthcare services across the continuum of care.