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The Effects of Intra-state Location on Treatment Compliance and Outcome Following Traumatic Brain Injury

Categories: Outcomes

The Question

Is intra-state location a factor in treatment compliance and outcome following traumatic brain injury (TBI)?

Past Studies

Past Studies have shown that people living in urban areas have better rehabilitation and outcome results following TBI than people living in rural areas. Mortality rates are higher for people living in rural settings, especially from motor vehicle collisions (MCVs). These facts are attributed to higher travel speeds, poorer road conditions, greater use of utility vehicles, and unavailability of adequate emergency care in rural areas. A comparison was made between patterns of injury and process of care in the United States and Scotland. In the Scotland study, there were not significant differences in mortality rates between rural and urban settings. This discrepancy was thought to be related to the fact that the mechanism for injury (MVCs, falls, violence-assaults) and severity of injury were not considered as variables in the findings. In addition to mortality rates, differences between rural and urban rates have been documented in TBI occurrence and outcome in these two countries. Mechanisms of injury differ across rural and urban settings. In the U.S., MVCs, assault and falls have been cited as leading causes of TBI.

A study in rural Virginia confirmed that MVCs, falls and assault are the most common mechanisms of injury and concluded that rural residents, 15-19 years of age, had twice the injury occurrence rate as the general rural population. Injury rates were higher for males, and non-Caucasians had a higher occurrence of TBI.

The Scotland sample showed trauma occurrence more likely in deprived (rural) areas, which is consistent with U.S. reports. However, the mode of injury differed across geographic settings. In the Scotland study, people living in less deprived (urban) areas were more likely to sustain TBI from traffic accidents whereas those in more rural areas were more often victims of assault. Mechanism of injury could explain greater urban mortality in the Scotland study. While researchers accurately documented prevalence and mortality rates, treatment compliance, level of functioning and outcome variables were less well documented. The latter areas are important for good health care planning and compiling reliable statistics regarding outcome following TBI.

An Iowa study found that individuals with TBI in rural areas were more functionally dependent (needed help with daily living activities) than individuals with TBI from urban areas. Functional status was a result of mechanism of injury, level of care in the acute phase of treatment, post- and sub-acute care, and community integration (return to the community). Research has shown that people with severe injuries and who receive inadequate care in the post-acute phase have difficulty with community re-entry, which might be delayed and/or unsuccessful. Need for services and access to services was not related to geographic area, and residents were equally likely to receive necessary acute services. Those who needed rehabilitation and did not receive it were twice as likely to be functionally dependent and in poor health, regardless of location.

A Colorado study found outcome barriers for females included lack of information services, travel distance and case coordination. Using these issues with 21 participants, negative attitudes and beliefs about seeking social support were related to ratings of lower quality of life, value of social support, whether participants were separated or divorced (lack of immediate family support) and living in an urban area.

Gaps exist in studies investigating outcomes of individuals with TBI in rural and urban settings. More studies are needed. Limited access to follow-up care for people in rural areas may cause poorer outcome, and travel distances may preclude people from getting necessary follow-up services causing poorer outcomes.

This Study

This Study examines the hypothesis that people residing greater distances from outpatient care and therapy services may have poorer compliance with follow-up treatment and medicine regimens, and may experience a greater incidence of medical complications. The study goal is to determine if patients with TBI, living in rural areas with less access to resources and amenities, have worse outcomes than patients living in urban areas with closer proximity to services.

The population studied consisted of TBI patients from two neurorehabilitation hospitals that are part of the National Institute on Disability and Rehabilitation (NIDRR) TBI Model Systems program. Criteria for inclusion in the study were a documented TBI, treatment at a Level 1 trauma center within 24 hours of injury, admission to acute care inpatient rehabilitation within 72 hours of discharge from acute care, inpatient rehabilitation received from a Model System facility, 16 years of age at time of injury, and the ability to give informed consent personally or by proxy. Participants admitted to the two Model Systems sites were injured between November 1, 1998 and May 30, 2002 (for study site 1) and April 1, 2001 and March 31, 2002 (for site 2). A total of 188 people were admitted to the study but only 152 could be contacted at follow-up for complete collection of data.

Data collected from hospital and emergency room records included information regarding severity of injury and course of medical care from hospital and emergency room records. Demographic information, including date of birth, education and marital status, was collected through interviews with participants, family members, caregivers, and significant others. Follow-up telephone calls, three to six weeks after discharge from inpatient rehabilitation, were made to collect information about living situation, follow-up care with physicians, medical complications experienced since discharge (falls, seizures, headaches, re-hospitalizations), location and nature of outpatient therapies, and compliance with treatment (mediations and therapy attendance).

The distance needed to travel to the physician for follow-up care and from the physician to outpatient therapy were two variables studied. Distance was calculated by using MapQuest, and available information about addresses or public service landmarks (post office, county facilities). The primary investigation site was in a southern state with a larger number of rural dwellers than many other states in the U.S.

Data analyses identified six variables as indicators of outcome. The degree of association between outcomes and distance from participants’ residence to outpatient therapy and physician follow-up locations was examined. Results found that the majority of participants experienced no medical complications and had one-hundred percent compliance with treatment during the first month following discharge from inpatient rehabilitation. A small number of participants experienced seizures (4.6%) and falls (18.5%) during this time period. The majority of participants (67.8%) reported no problems with headaches, with the remainder of participants having headaches varying from one per day to one per month. One hundred-five participants were prescribed outpatient treatment, and 67.6% were fully compliant with treatment. One hundred-thirty-three participants had been prescribed medication, and 95.3% complied without deviation. The relationship between outcomes and distance from physician follow-up or distance from outpatient treatment was not significant. There was no significant association among outcome and distance variables and participant age or race/ethnicity.

Who May Be Affected By These Findings

People with brain injury and their families, health professionals, community agencies, caregivers, and researchers.


This study was a unique attempt to examine the relationship between distance, as a variable affecting availability of and participation in services by people with TBI, following discharge from inpatient rehabilitation, and how it would ultimately limit positive medical outcomes. Further research would be beneficial if the studies looked at collection of data beyond one month and used objective methods in the collection process. This study relied on self-reporting from the person with TBI or family member. Inaccuracies and overestimations are possible given the high compliance rates. Specific definitions of medical complications (falls, headaches, and seizures) were not given to participants at the time of the interview, leaving open the possibility of subjective interpretation.

Bottom Line

Findings suggested that distance did not seem to be of significance in terms of outcome. Adherence to follow-up treatment and therapy was high although many participants relied on the assistance of others for transportation to appointments and medication management.

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Anderson, S., Gontkovsky, S.T., Sherer, M., Nakase-Thompson, R., Yablon, S.A., Sander, A., High, Jr., W.M. (2004). The Effects of Intra-state Location on Treatment Compliance and Outcome Following Traumatic Brain Injury.The Journal of Cognitive Rehabilitation, 2-6.




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