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Awarded Research Cooperative Agreement - Acute Care

Studies to Determine the Prevalence of a History of Traumatic Brain Injury (TBI) in an Institutionalized Population

FOA Number: CE07-008: The Impact of Traumatic Brain Injury Among Incarcerated Persons
Project Period: 09/01/04- 08/31/05
Application/Grant Number: 1-U49-CE001301-01
Principal Investigator: Pamela Diamond, Ph.D.
University of Texas at Houston
School of Public Health
7000 Fannin, suite 2614
Houston TX 77030
Phone: 713-500-9979
Fax: 713-500-9602

Barbara A. Gabella
Colorado Dept. of Public Health & Environment
4300 Cherry Creek Dr., South
Denver, CO 80246-1530
Phone: (303) 692-3003
Fax: (303) 691-7901


The purpose of this program is to fund a cooperative agreement to conduct pilot studies to investigate methods for determining the prevalence of a history of traumatic brain injury (TBI) in an institutionalized population. For purposes of this project, “institutionalized” refers to persons who are either incarcerated or residing in a nursin home.

Anecdotal reports suggest that a very large proportion of the prison population may have experienced one or more TBIs, with many of them occurring prior to incarceration. The cognitive deficits that can result from traumatic brain injuries often are not visible, and behavioral and emotional problems associated with TBI may be attributed to other causes. Thus, prisoners with TBI as well as prison officials may not be aware of the signs, symptoms, and long-term problems resulting from TBI, and therefore may not seek or provide appropriate treatment or other interventions. Better methods for identifying incarcerated persons with a history of TBI and related problems could lead to improved management of TBI in this population.

An estimated 20 to 30 percent of persons hospitalized with moderate to severe TBI are discharged to nursing homes, including those for long-term care. Not all of the persons with TBI who are discharged to nursing homes are elderly, but little is known about the age distribution and other characteristics of this population. Of note, research on a small number of persons with TBI residing in long-term nursing facilities found that, with the proper rehabilitation, they recovered sufficient function to return home or live in a supported community living environment. Better information on the number and characteristics of persons with TBI living in nursing homes, including their functional levels, would inform the development of policies to ensure that they receive appropriate rehabilitation services that can help them return to the community.

Two projects, one at the University of Texas at Houston, and one at the Colorado Department of Public Health and the Environment, are currently funded from this Program Announcement.

University of Texas at Houston

As prison populations across the country grow, there is a need for greater understanding of the health needs of this diverse population. Prison inmates often come from poverty situations where health care options are limited. They are likely to have abused both legal and illegal substances, and they engage in activities that put them at risk of both unintentional and intentional injury. These factors combine to place this population at high risk of experiencing Traumatic Brain Injury (TBI), which may be medically under-treated and exacerbated by subsequent substance use. TBI often results in behavioral symptoms, which, if untreated, can lead to difficulties in adjustment to prison life and may make successful reintegration into the community upon release less likely. There is little research available on the prevalence of TBI history among prison inmates. This study will begin to address a gap in the literature by developing and validating a brief interview instrument to assess history of TBI among prison inmates.

The availability of a reliable, valid and efficient assessment instrument will make it possible in the future for prison services personnel to screen for head injury as a part of standard operations, thus facilitating earlier identification of TBI in this population and allowing for more appropriated assignment to treatment and rehabilitation during incarceration. This research builds upon an ongoing study of the prevalence of mental heath problems among the federal prison population (The Mental Health Prevalence Study: MHPS) that has collected both self-report and archival data from over 2000 inmates from 13 prison units across the country.

The specific aims of the study are: 1) To develop an efficient interview based instrument for assessing a history of TBI in a civilian prison population, and 2) To develop a feasible plan/proposal for assessing the prevalence of TBI among the federal prison inmate population using the validated instrument and related measures of cognitive, behavioral and psychological function.

Colorado Department of Health and Environment

The federal Centers for Medicare and Medicaid Services (CMS) requires all nursing homes utilizing Medicare or Medicaid reimbursement to assess their residents at admission, quarterly, annually, and whenever there is a significant change in the resident’s status. CMS requires nursing homes to use the standardized Minimum Data Set (MDS) for reporting. This assessment tool provides comprehensive information on the resident, including cognitive and physical function, activities of daily living, disease and injury diagnoses, discharge potential and psychosocial status. Though several items on the MDS have been validated, history of having had a traumatic brain injury (TBI) has not.

Jointly, two divisions at the Colorado state health department propose validating the TBI idem and TBI-related ICD-9 codes on the MDS. This validation could streamline the eligibility process for the new Colorado TBI trust fund, potentially leading to additional services being available to nursing home residents with TBI.

The Colorado pilot study will have similar important implications for nursing home residents in other states, since and estimated 95% of the nursing homes in the U.S. must use the MDS and since 14 other states have TBI trust funds that pay for services. If the aims of the research prove successful, other states could partner with CMS and replicate the methods to validate the TBI diagnosis for their MDS and determine the prevalence of TBI in nursing homes in their own states.

The specific aims of this project are: 1) to validate the diagnosis of TBI on the Resident Assessment Instrument's Minimum Data Set (MDS) Tool, a federally-mandated data system used by all nursing homes in the United States; 2) to identify cases of TBI missed by the MDS; 3) to use the MDS, if valid, to determine the prevalence of TBI in nursing home residents in Colorado; and 4) to describe functional status as measured by the activities of daily living and demographic characteristics of nursing home residents with TBI in Colorado. Investigators will seek approval from the Centers for Medicare and Medicaid Services (CMS) to use part of the MDS data for this project, by completing the CMS process to obtain a data use agreement. For a random sample of nursing home residents with an ICD-9-CM code for TBI or a diagnosis of TBI on the MDS, investigators will verify the TBI using three sources of medical information: medical records at the nursing homes, inpatient medical records, and data from the Colorado TBI surveillance system. If a medical diagnosis of TBI or the clinical criteria for TBI as defined by CDC is documented in any of the three sources, then the TBI on the MDS will be considered accurate. To quantify the accuracy of TBI on the MDS for the sample of residents, the investigators will calculate the positive predictive value. Under the provisions of a data use agreement with CMS, investigators will analyze the demographic characteristics and activities of daily living for residents with TBI.