Health Disparities and TBI
Health disparities are differences in health outcomes and their causes among groups of people.1 Groups can be defined by factors such as race, ethnicity, sex, education, income, disability, geographic location (e.g., rural or urban), or sexual orientation and gender identity. When examining disparities in TBI, CDC analyzes differences in incidence rates, prevalence rates, and outcomes by group.
Which groups are most affected by TBI?
TBI has contributed to the deaths of more than one million Americans over the last two decades.2 For survivors, a TBI can lead to short- or long-term problems that may affect all aspects of a person’s life, including the ability to work3,4 or build relationships with others,5 and it can change how a person thinks, acts, feels, and learns. While anyone is at risk for getting a TBI, some groups have a greater likelihood of dying from a TBI or living with long-term problems that resulted from the injury.6
Certain racial and ethnic groups have a higher chance of sustaining a severe TBI.
American Indian/Alaska Native children and adults have higher rates of TBI-related hospitalizations and deaths than other racial or ethnic groups.2,7-9 Factors that contribute to this disparity include higher rates of motor vehicle crashes,10 substance use,10 and suicide11 as well as difficulties in accessing appropriate health care.12
In addition to differences in rates of TBI, racial and ethnic minority groups, particularly non-Hispanic black and Hispanic patients, are less likely to receive follow-up care and rehabilitation following a TBI compared to non-Hispanic white patients.13-18 Racial and ethnic minorities are also more likely to have poor psychosocial, functional, and employment-related outcomes after sustaining a TBI than non-Hispanic white individuals.19-23
People with lower incomes and those without health insurance have less access to TBI care.
Survivors of a moderate or severe TBI may face a difficult road to recovery that requires services such as physical therapy and mental health treatment for months or years in order to return to pre-injury function. For TBI survivors with lower incomes or who are uninsured, there can be significant barriers in accessing appropriate TBI care. Compared with patients who have private health insurance, those who are uninsured are:
- Less likely to receive a TBI procedure (e.g., craniectomy/craniotomy, ventriculostomy, intracranial pressure monitor placement, arterial line placement, and central line placement).24
- Less likely to receive inpatient services, such as rehabilitation.6,18,25,26
- More likely to die in the hospital.27
People in rural areas are more likely to die from a TBI.
People living in rural areas have a greater risk of dying from a TBI compared to people living in urban areas.28-32 Some reasons for this disparity include:
- More time needed to travel to emergency medical care.33
- Less access to a Level I trauma center (the highest level of medical care).34
- Difficulty getting services, such as specialized TBI care.35,36
Children living in rural areas are more likely to get a TBI and to die as a result of this injury compared to children living in urban areas.31 Children in rural areas may also be more likely to:
- Experience delays in getting TBI-related care.36
- Be unnecessarily transferred to another hospital for TBI-related care.36
What is CDC doing to reduce health disparities that increase the risk for TBI?
Reducing disparities is an important part of preventing TBI and lowering the chance for serious long-term health problems following a TBI. CDC has research underway to better understand and inform the development of programs to reduce health disparities that increase the risk for TBI and other injuries. In addition, CDC is creating resources for healthcare providers that can improve TBI care for all Americans. Some examples of these efforts include:
Conducting surveillance and research to support data-driven solutions.
A recent CDC surveillance report found American Indian/Alaska Natives consistently had the highest age-adjusted rates of TBI-related deaths from 2000-2017 and motor vehicle crashes accounted for the highest rate of these TBI-related deaths in all study years.9 In support of preventing motor vehicle crash-related injuries and deaths among tribal nations, CDC developed the Roadway to Safer Tribal Communities Toolkit. The toolkit’s posters, fact sheets, and video include important actions to increase safety on the road, such as increasing child safety seat use, increasing seat belt use, and decreasing alcohol-impaired driving.
Using virtual training programs to educate and provide support to healthcare providers and school professionals in rural areas caring for and helping individuals with TBI.
In partnership with the American Academy of Pediatrics, CDC developed and piloted pediatric mild TBI and concussion-specific telehealth initiatives using the Project ECHO methodology.37 These initiatives train two groups that are significantly involved in managing pediatric mild TBI—rural primary care providers and school professionals. ECHO uses video conferencing to train how to treat and manage complex diseases that would often need referral to a specialist. Over 150 people have participated in the ECHO programs to date, positively impacting thousands of children who have sustained a mild TBI.
Releasing clinical guidelines on mild TBI to ensure all patients get the best care possible.
CDC has developed guidelines for healthcare providers who care for children and adults with mild TBI and concussion. Since their publication, CDC has worked to increase use of these guidelines among healthcare providers to ensure that all patients receive care based on the best available science.
- Centers for Disease Control and Prevention. Community Health and Program Services (CHAPS): Health Disparities Among Racial/Ethnic Populations. Atlanta: U.S. Department of Health and Human Services,;2008.
- Daugherty J, Waltzman D, Sarmiento K, Xu L. Traumatic Brain Injury–Related Deaths by Race/Ethnicity, Sex, Intent, and Mechanism of Injury — United States, 2000–2017. MMWR Morbidity and Mortality Weekly Reports. 2019;68(46):1050-1056.
- Dillahunt-Aspillaga C, Nakase-Richardson R, Hart T, et al. Predictors of Employment Outcomes in Veterans With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study. Journal of Head Trauma Rehabilitation. 2017;32(4):271-282.
- Cuthbert JP, Harrison-Felix C, Corrigan JD, Bell JM, Haarbauer-Krupa JK, Miller AC. Unemployment in the United States after traumatic brain injury for working-age individuals: prevalence and associated factors 2 years postinjury. Journal of Head Trauma Rehabilitation. 2015;30(3):160-174.
- Sirois K, Tousignant B, Boucher N, et al. The contribution of social cognition in predicting social participation following moderate and severe TBI in youth. Neuropsychological Rehabilitation. 2017:1-16.
- Gao S, Kumar RG, Wisniewski SR, Fabio A. Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review. Journal of Head Trauma Rehabilitation. 2018;33(3):E40-e50.
- Rutland-Brown W, Wallace LD, Faul MD, Langlois JA. Traumatic brain injury hospitalizations among American Indians/Alaska Natives. Journal of Head Trauma Rehabilitation. 2005;20(3):205-214.
- Langlois JA, Kegler SR, Butler JA, et al. Traumatic brain injury-related hospital discharges. MMWR Surveillance Summaries. 2003;52(4):1-20.
- Peterson AB, Sarmiento K, Xu L, Haileyesus T. Traumatic brain injury-related hospitalizations and deaths among American Indians and Alaska natives – United States, 2008-2014. Journal of Safety Research. 2019;71:315-318.
- Murphy T, Pokhrel P, Worthington A, Billie H, Sewell M, Bill N. Unintentional injury mortality among American Indians and Alaska Natives in the United States, 1990-2009. American Journal of Public Health. 2014;104 Suppl 3:S470-480.
- Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A, Fowler KA. Suicides Among American Indian/Alaska Natives – National Violent Death Reporting System, 18 States, 2003-2014. MMWR Morbidity and Mortality Weekly Reports. 2018;67(8):237-242.
- Anderson ES, Greenwood-Ericksen M, Wang NE, Dworkis DA. Closing the gap: Improving access to trauma care in New Mexico (2007-2017). The American Journal of Emergency Medicine. 2019.
- Dismuke CE, Gebregziabher M, Egede LE. Racial/Ethnic Disparities in VA Services Utilization as a Partial Pathway to Mortality Differentials Among Veterans Diagnosed With TBI. Global Journal of Health Science. 2015;8(2):260-272.
- Jimenez N, Quistberg A, Vavilala MS, Jaffe KM, Rivara FP. Utilization of Mental Health Services After Mild Pediatric Traumatic Brain Injury. Pediatrics. 2017;139(3).
- Jimenez N, Symons RG, Wang J, et al. Outpatient Rehabilitation for Medicaid-Insured Children Hospitalized With Traumatic Brain Injury. Pediatrics. 2016;137(6).
- Meagher AD, Beadles CA, Doorey J, Charles AG. Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury. Journal of Neurosurgery. 2015;122(3):595-601.
- Schiraldi M, Patil CG, Mukherjee D, et al. Effect of insurance and racial disparities on outcomes in traumatic brain injury. Journal of Neurological Surgery. 2015;76(3):224-232.
- Asemota AO, George BP, Cumpsty-Fowler CJ, Haider AH, Schneider EB. Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. Journal of Neurotrauma. 2013;30(24):2057-2065.
- Arango-Lasprilla JC, Ketchum JM, Gary K, et al. Race/ethnicity differences in satisfaction with life among persons with traumatic brain injury. NeuroRehabilitation. 2009;24(1):5-14.
- Arango-Lasprilla JC, Ketchum JM, Lewis AN, Krch D, Gary KW, Dodd BA, Jr. Racial and ethnic disparities in employment outcomes for persons with traumatic brain injury: a longitudinal investigation 1-5 years after injury. PM & R : The Journal of Injury, Function, and Rehabilitation. 2011;3(12):1083-1091.
- Arango-Lasprilla JC, Kreutzer JS. Racial and ethnic disparities in functional, psychosocial, and neurobehavioral outcomes after brain injury. Journal of Head Trauma Rehabilitation. 2010;25(2):128-136.
- Arango-Lasprilla JC, Rosenthal M, Deluca J, et al. Traumatic brain injury and functional outcomes: does minority status matter? Brain Injury. 2007;21(7):701-708.
- Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences exist in post-injury outcomes after TBI? A comprehensive review of the literature. Brain Injury. 2009;23(10):775-789.
- Missios S, Bekelis K. The association of insurance status and race with the procedural volume of traumatic brain injury patients. Injury. 2016;47(1):154-159.
- Haines KL, Nguyen BP, Vatsaas C, Alger A, Brooks K, Agarwal SK. Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury. Journal of Surgical Research. 2019;235:131-140.
- Kane WG, Wright DA, Fu R, Carlson KF. Racial/ethnic and insurance status disparities in discharge to posthospitalization care for patients with traumatic brain injury. Journal of Head Trauma Rehabilitation. 2014;29(6):E10-17.
- McQuistion K, Zens T, Jung HS, et al. Insurance status and race affect treatment and outcome of traumatic brain injury. Journal of Surgical Research. 2016;205(2):261-271.
- Chapital AD. Traumatic brain injury: outcomes of a rural versus urban population over a 5 year period. Manoa, Hawaii: University of Hawaii Biomedical Sciences, University of Hawaii; 2005.
- Bazarian JJ, McClung J, Shah MN, Ting Cheng Y, Flesher W, Kraus J. Mild traumatic brain injury in the United States, 1998–2000. Brain Injury. 2005;19(2):85-91.
- Johnstone B, Nossaman LD, Schopp LH, Holmquist L, Rupright SJ. Distribution of services and supports for people with traumatic brain injury in ruraland urban Missouri. Journal of Rural Health. 2002;18(1):109-117.
- Leonhard MJ, Wright DA, Fu R, Lehrfeld DP, Carlson KF. Urban/Rural disparities in Oregon pediatric traumatic brain injury. Injury Epidemiology. 2015;2(1):32.
- Gabella B, Hoffman RE, Marine WW, Stallones L. Urban and rural traumatic brain injuries in Colorado. Annals of Epidemiology. 1997;7(3):207-212.
- Jarman MP, Castillo RC, Carlini AR, Kodadek LM, Haider AH. Rural risk: Geographic disparities in trauma mortality. Surgery. 2016;160(6):1551-1559.
- Carr BG, Bowman AJ, Wolff CS, et al. Disparities in access to trauma care in the United States: A population-based analysis. Injury. 2017;48(2):332-338.
- Graves JM, Mackelprang JL, Moore M, et al. Rural-urban disparities in health care costs and health service utilization following pediatric mild traumatic brain injury. Health Service Research. 2019;54(2):337-345.
- Yue JK, Upadhyayula PS, Avalos LN, Cage TA. Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations. Brain Sciences. 2020;10(3):135.
- University of New Mexico School of Medicine. Project ECHO. 2020; https://echo.unm.edu/external icon. Accessed June 30, 2020.