Association of neighborhood disadvantage with clinical and healthcare utilization outcomes following traumatic brain injury.

BACKGROUND

Health disparities in traumatic brain injury (TBI) risk and outcomes have been observed. Neighborhood-level social determinants of health (SDOH), such as built environment and socioeconomic disadvantage, may contribute to these disparities. To improve understanding of how neighborhood characteristics impact care for critically ill patients with moderate-severe TBI (msTBI), we examined the association of neighborhood socioeconomic disadvantage with clinical and healthcare utilization outcomes following msTBI.

METHODS

We conducted a retrospective cohort study, utilizing data from msTBI patients admitted to an intensive care unit at Duke University Hospital (DUH) from 2016 to 2024. Area Deprivation Index (ADI), ascertained from the electronic health record, was the primary exposure, with higher ADI indicating higher neighborhood socioeconomic disadvantage. The primary outcomes were palliative care utilization and hospital mortality, and secondary outcomes included: tracheostomy utilization, gastrostomy tube utilization, and discharge disposition (including acute rehabilitation utilization). Multi-variable logistic regression and survival models with sequential risk-adjustment were used to examine associations of ADI with clinical outcomes.

RESULTS

Of the initial cohort, 1,252 patients met inclusion criteria (mean age 56.2 years, 66.4 % male, 50.7 % white, 37.0 % black, 7.7 % Hispanic, 4.6 % other). The mean (SD) ADI percentile was 58.7 (24). In tertiles, the low disadvantage (ADI 0-33 percentile), moderate disadvantage (ADI 34-66 percentile), and high disadvantage (ADI 67-100 percentile) groups composed 31.6 %, 34.0 %, and 34.3 % of the cohort, respectively. In fully adjusted models, higher ADI was associated with reduced utilization of palliative care (OR 0.92, CI 0.85-0.98) and reduced hospital mortality (OR 0.92, CI 0.85-0.98). Higher ADI was associated with greater utilization of tracheostomy (OR 1.11, CI 1.03-1.20) and gastrostomy (1.08, 1.01-1.16) tubes in crude models and partially adjusted models, but associations became attenuated with full risk adjustment. ADI was not associated with differences in discharge disposition to home/rehabilitation.

CONCLUSION

This study demonstrates that greater neighborhood disadvantage is associated with reduced palliative care utilization, reduced hospital mortality, and trends toward greater utilization of life-sustaining procedures among critically ill patients following msTBI. Neighborhood-level factors may impact TBI outcomes beyond individual-level SDOH factors alone. Further research should confirm and examine the mechanisms underlying these findings.