Trajectories of Recovery Following Traumatic Brain Injury Among Older Medicare Beneficiaries

It is well-known that older adults have poorer recovery following traumatic brain injury (TBI) relative to younger adults with similar injury severity. However, most older adults do recover well from TBI. Identifying those at increased risk of poor recovery could inform appropriate management pathways, facilitate discussions about palliative care or unmet needs and permit targeted intervention to optimize quality of life or recovery. We sought to explore heterogeneity in recovery from TBI among older adults as measured by home time per month, a patient-centered metric defined as time spent at home and not in a hospital, urgent care, or other facility. Using data obtained from Medicare administrative claims data for years 2010-2018, group-based trajectory modelling was employed to identify unique trajectories of recovery among a sample of United States adults aged 65 and older who were hospitalized with TBI. We next determined which patient-level characteristics discriminated poor from favorable recovery using logistic regression. Among 20,350 beneficiaries, four unique trajectories were identified: poor recovery (n=1,929 (9.5%)), improving recovery (n=2,793 (13.7%)), good recovery (n=13,512 (66.4%)), and declining recovery (n=2,116 (10.4%)). The strongest predictors of membership in the poor relative to the good recovery trajectory group were diagnosis of Alzheimer's disease and related dementias (odd ratio (OR) 2.42; 95% confidence interval (CI) 2.16, 2.72) and dual eligibility for Medicaid, a proxy for economic vulnerability (OR 5.13; 95% CI 4.59, 5.74). TBI severity was not associated with recovery trajectories. In conclusion, this study identified four unique trajectories of recovery over one year following TBI among older adults. Two-thirds of older adults hospitalized with TBI returned to the community and stayed there. Recovery of monthly home time was complete for most by three months post injury. An important sub-group comprising 10% of patients who did not return home was characterized primarily by eligibility for Medicaid and diagnosis of ADRD. Future studies should seek to further characterize and investigate identified recovery groups to inform management and development of interventions to improve recovery.