Follow-Up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury

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1 J Head Trauma Rehabil Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved. Follow-Up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury Alexandra J. Spaw, BS; Jennifer P. Lundine, PhD, CCC-SLP; Sarah A. Johnson, BA; Jin Peng, MD, MS; Krista K. Wheeler, MS; Junxin Shi, MD, PhD; Ginger Yang, PhD; Kathy J. Haley, BSN, MS, RN; Jonathan I. Groner, MD; Henry Xiang, MD, PhD Objective: To investigate factors associated with follow-up care adherence in children hospitalized because of traumatic brain injury (TBI). Design: An urban level 1 children s hospital trauma registry was queried to identify patients (2-18 years) hospitalized with a TBI in 2013 to Chart reviewers assessed discharge summaries and follow-up instructions in 4 departments. Main Measures: Three levels of adherence nonadherence, partial adherence, and full adherence and their associations with care delivery, patient, and injury factors. Results: In our population, 80% were instructed to follow up within the hospital network. These children were older and had more severe TBIs than those without follow-up instructions and those referred to outside providers. Of the 352 eligible patients, 19.9% were nonadherent, 27.3% were partially adherent, and 52.8% were fully adherent. Those recommended to follow up with more than 1 department had higher odds of partial adherence over nonadherence (adjusted odds ratio [AOR] = 5.8, 95% CI: ); however, these patients were less likely to be fully adherent (AOR = 0.1; 95% CI: ). Privately insured patients had a higher AOR of full adherence. Conclusions: Nearly 20% of children hospitalized for TBI never returned for outpatient follow-up and 27% missed appointments. Care providers need to educate families, coordinate service provision, and promote long-term monitoring. Key words: pediatric, rehabilitation, service utilization, traumatic brain injury IN THE UNITED STATES, an estimated 700,000 children 0 to 19 years of age experience a traumatic brain injury (TBI) each year, making it the leading cause of death and disability for children. 1 Traumatic brain injury often becomes invisible after hospitalization because its manifestations are not always readily Author Affiliations: The Ohio State University College of Medicine (Ms Spaw and Drs Yang, Groner, and Xiang), Division of Clinical Therapies, Nationwide Children s Hospital (Dr Lundine), Center for Pediatric Trauma Research, The Research Institute at Nationwide Children s Hospital (Mss Johnson, Wheeler, and Haley, and Drs Peng, Shi, Yang, Groner, and Xiang), Center for Injury Research and Policy, The Research Institute at Nationwide Children s Hospital (Ms Johnson and Wheeler and Drs Peng, Shi, Yang, and Xiang), College of Public Health, The Ohio State University (Dr Peng), and Trauma Program, Nationwide Children s Hospital (Ms Haley and Dr Groner), Columbus, Ohio. This study was funded in part by The Ohio State University College of Medicine s Bennet Research Scholarship awarded to Alexandra Spaw, and an internal fund of Nationwide Children s Hospital. The authors declare no conflicts of interest. Corresponding Author: Henry Xiang, MD, MPH, PhD, Center for Injury Research and Policy, The Research Institute at Nationwide Children s Hospital, 700 Children s Dr, Columbus, OH (Henry.Xiang@NationwideChildrens.org). DOI: /HTR observable. 2,3 Thus, children with behavioral, cognitive, and social challenges may not receive the appropriate support services. 4 7 Evidence now suggests that TBIs, especially moderate and severe injuries, may be chronic, continually evolving disease processes rather than simply acute injuries with predictable consequences Even in children with mild TBI, persistent behavioral challenges have been reported 1 year postinjury. 11 Because of the unique properties of the developing brain, extended follow-up care may be required to ensure that children and adolescents achieve optimal long-term outcomes Previous researchers have described unrecognized and unmet needs after pediatric TBI. 6,7 Greenspan and MacKenzie 6 found that fewer than 20% of their pediatric patients with TBIs accessed healthcare services in the first year after injury, though 30% to 40% of the study sample reported unmet healthcare needs related to physical and occupational therapy and behavioral challenges. Slomine and colleagues 7 found similar results when surveying families of children and adolescents following TBI at 3 and 12 months postinjury. The most frequent unmet or unrecognized need cited in their sample was for cognitive services. To achieve successful long-term outcomes for children and adolescents with 1

2 2 JOURNAL OF HEAD TRAUMA REHABILITATION TBI, both the families affected by TBI and the medical professionals who provide services must be familiar with the complex, long-term challenges associated with such injuries. 6,9 Adherence with recommended follow-up healthcare can be affected by many factors, and children are dependent upon their caregivers. 15 Studies examining adherence for other pediatric conditions have found that barriers include geographic distance, transportation issues, dislike of the clinical environment, scheduling challenges, and forgetfulness Other studies have reported that maternal depression, illness severity, and the number of follow-up appointments can negatively affect adherence. 19,20 Improving adherence to follow-up appointments could allow for more patient education, better surveillance for persistent or new symptoms, and the identification of needed therapeutic interventions. In one study, nearly 50% of children who required hospitalization for mild TBI did not return for follow-up. 21 Poor compliance with return-to-play guidelines has also been reported in high school athletes following concussion, with many athletes returning before recommended waiting periods have passed. 22 Thus, as longitudinal followup for children and adolescents with TBI is increasingly viewed as important, clinicians and researchers must understand the factors related to adherence within this population. In this study, we investigated adherence with followup appointments at one academic hospital with integrated care, including a level 1 trauma center and both inpatient and outpatient rehabilitation services. Prior to this study, the proportion of patients returning for their recommended follow-up care was not known. We sought to identify factors that contribute to low adherence among children and adolescents with TBI after their hospital discharge. Identifying these factors will allow healthcare organizations and funding agencies to target modifiable factors to increase adherence with follow-up care and potentially improve the longterm outcomes for these children. METHODS This project was a single-site retrospective chart review from an independent, urban, children s hospital with an on-site level 1 trauma center. Its rehabilitation unit has accreditation from the Commission on Accreditation of Rehabilitation Facilities. This study was approved by the hospital s institutional review board. Chart reviewers for this study were a medical student and a research assistant. They were trained on specifics of the electronic medical record (EMR) by the clinical research coordinator/speech pathologist, who has more than 10 years clinical experience documenting in the EMR. Source of data and study population We first used our institution s trauma registry to identify patients who met the following criteria: ages 2 to 18 years, discharged from an inpatient unit, January 1, 2013, to December 31, 2014, with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code indicating a TBI. We requested registry data for those meeting the Centers for Disease Control and Prevention recommended ICD-9 definition ( , , , , and ) with one exception. Since nonaccidental injury is a common cause of TBI for infants with unique issues (eg, increased likelihood that children are placed in protective custody or have changes in guardianship) that might skew adherence data, we excluded children younger than 2 years, and we did not use the recommended TBI code for shaken baby syndrome, Children with the maltreatment code were included if they also had TBI codes in the ranges listed earlier. The initial trauma registry request also included patients with the codes (open wound of the head or scalp). We retrieved the following information from our trauma registry: medical record number, age, sex, race/ethnicity, insurance status, cause of injury, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (head AIS) score, Injury Severity Score (ISS), length of stay (LOS), and hospital disposition. We also used the ICD-9-CM codes to describe the injuries by TBI type, groupings based on the presence/absence of intracranial injury, and the duration of loss of consciousness (LOC). 23 Type 1 TBI is the most severe and includes intracranial injury or moderate or prolonged LOC or injuries to the optic nerve pathways. Type 2 TBI includes injury with no recorded evidence of intracranial injury, and LOC of less than 1 hour, unknown duration, or unspecified. Type 3 TBI includes head injury with no reported intracranial injury and no LOC. Chart reviewers used the medical record number to access the EMR to examine discharge summaries and patient instructions for follow-up care and subsequent adherence with recommended appointments. Chart review Each eligible chart was examined by two independent reviewers and their ratings of level of adherence for each patient were compared. When the ratings differed, agreement was reached through consultation with one another and consensus with other authors. This minimized bias due to subjectivity in the rating of adherence. Discharge summaries and patient instructions for follow-up were placed into two categories by chart reviewers: specific (date, time, location of follow-up visit listed on the discharge instructions) or nonspecific

3 Follow-up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury 3 (listing the recommendation for an appointment, but without details regarding the date and time). Followup appointment adherence was tracked if orders were specifically related to the TBI and if patients were referred to the following clinics: physical medicine and rehabilitation (PM&R), primary care (pediatrics or family medicine), neurosurgery, and sports medicine. Occupational therapy, physical therapy, and speech pathology services were not provided in clinics other than the rehabilitation follow-up clinic. The rehabilitation follow-up clinic currently allows for screenings from all providers involved in the patient s inpatient rehabilitation admission. We attempted to only track those appointments that were related to the TBI admission (eg, we did not track/evaluate adherence for appointments made before sustaining a TBI for speech therapy related to preexisting conditions). For each appointment, patient instructions were reviewed to evaluate recommendations for subsequent appointments. Follow-up appointment adherence Adherence was assessed for all appointments in each department listed in the patient s discharge instructions and marked as full, partial, nonadherent, or ongoing treatment within the different clinic categories. Full adherence indicated that patients attended all recommended visits within 4 weeks of the recommended follow-up window and were subsequently discharged with no further recommended care. Partial adherence indicated that patients attended at least 1 recommended follow-up visit within 4 weeks of the department s recommended follow-up window. Patients with partial adherence in a subspecialty may have attended followup more than a month after the recommended time frame or attended 1 or more follow-up appointments but did not return for an additional recommended appointment. The partial adherent group includes those who were fully adherent in one department but nonadherent or partially adherent in another. Nonadherence indicated that patients did not return for even 1 follow-up appointment despite the recommendation to do so. Patients who were discharged in 2013 and had ongoing treatment were treated as fully adherent, because these patients were fully adherent up to that point and had attended all recommended visits for at least 18 months. Sometimes the clinics rescheduled the appointments. The time frame for adherence was then applied to the rescheduled appointment time. We had access to documented telephone encounters, so we were able to assess why appointments were rescheduled. We excluded patients who were discharged in 2014 with ongoing treatment, because we could not classify their level of adherence at the time of the chart review. Statistical analysis Data were analyzed using SAS 9.3 (Cary, North Carolina). We first compared our sample of patients with follow-up care instructions to 2 other subsets of patients: those without instructions and patients instructed to follow up with a provider outside the hospital s network. We then focused on the patients who were instructed to follow up within our network of care and evaluated their adherence. A chi-square test or Fisher exact test (for variables with small numbers) was performed to assess the association between follow-up adherence and care delivery, patient, and injury factors. Care delivery factors included specificity of the follow-up instructions (eg, specific or nonspecific) and follow-up department. Patient factors included sex, age, race, and medical insurance status. Injury factors were related to the cause of injury and measures of severity (GCS, head AIS, ISS, TBI type, LOS, and hospital disposition to rehabilitation or home). We considered using ordinal regression to evaluate the 3 levels of adherence (nonadherence, partial adherence, and full adherence) in one model, but the proportional odds assumption (the assumption that the relations between each pair of outcome groups are the same) was not met. Therefore, we used 2 main logistic regression models, structuring the models to mimic an ordinal approach. The first model examines the odds of partial adherence over nonadherence. The second model examines the odds of full adherence over partial adherence. We report the multivariable results for both models. The independent variables were care delivery, patient, and injury factors. Injury severity variables were individually added to regression models to avoid collinearity. Statistical significance was set at P <.05. RESULTS Figure 1 shows the results of the chart review process during which we excluded the following: deceased patients, those with inaccessible charts, and those whose treatment while hospitalized were related to a non-tbi diagnosis. Of the 463 eligible children, 40 (8.6%) were given no follow-up instructions, 53 (11.4%) were instructed to follow up with outside providers only, and 370 (79.9%) were instructed to follow up within the hospital network (see Table 1). Children instructed to follow up with hospital network providers were older (P <.0001) and had more severe TBIs (P =.03). Two patients were transferred to another hospital, and there were 16 patients (4.3%) with ongoing treatment; these patients were excluded from the adherence analyses. Table 2 shows patient adherence status. Of the 352 patients who were instructed to follow up within the hospital network, 19.9% were nonadherent with

4 4 JOURNAL OF HEAD TRAUMA REHABILITATION Figure 1. Chart review. Breakdown of patients aged 2 to 18 years hospitalized between 2013 and 2014 with a TBIrelated diagnosis. a Includes 13 patients with ongoing treatment who are fully compliant for 18 months. follow-up, 27.3% were partially adherent, and 52.8% were fully adherent. Adherence status differences were seen across the following categories: follow-up department, age, and insurance status. The majority of patients (64.5%) were asked to return only to physical medicine and rehabilitation; full adherence (59.9%) was highest for this department. Only 36.8% of those asked to return to more than 1 department were fully adherent. Younger children (2- to 4-year-olds) were 11.6% of the evaluated sample, but 43.9% of this age group were nonadherent. Patients with private insurance were most often fully adherent and least often nonadherent. The results of the logistic regression models are shown in Table 3. The effect of each severity measure was examined in separate models, because the severity measures are correlated with each other; only the model with the GCS is shown in Table 3 for reasons described later. We chose to put all covariates in the multivariate models to account for any potential residual confounding. In the adjusted analysis, the following factors continued to be associated with adherence: follow-up department, age, and insurance status. Specifically, compared with patients with follow-up only in physical medicine and rehabilitation, those with follow-up in more than 1 department had higher odds of partial adherence over nonadherence (the adjusted odds ratio [AOR] = 5.8; 95% CI: ). However, patients with follow-up in more than 1 department had lower odds of full adherence over partial adherence (AOR = 0.1; 95% CI: ). Age had a similar relation to adherence. Older children were more likely to be partially adherent (rather than nonadherent), but they were also less likely to be fully adherent (rather than partially adherent). Compared with the youngest patients (2- to 4-year-olds), older patients (11- to 15-year-olds) had a higher odds ratio of partial adherence over nonadherence (AOR = 4.6; 95% CI: ). Similarly, 16- to 18-year-olds had a marginally higher odds ratio of partial adherence. However, patients aged 16 to 18 years had lower odds of full adherence over partial adherence (AOR = 0.1; 95% CI: ), and 11- to 15-year-olds had a marginally lower odds of full adherence (AOR = 0.3; 95% CI: ). Insurance status did not affect the odds of partial adherence over nonadherence but did affect the odds of full adherence. Compared with patients with Medicaid or Medicare, those with private insurance had higher odds of full adherence over partial adherence (AOR = 3.5; 95% CI: ). None of the severity measures (GCS, head AIS, ISS, TBI type, LOS, and hospital disposition to rehabilitation) were statistically significant, but they each changed the other AORs in the model in similar ways, both direction and magnitude. For this reason, we chose to only show the GCS in our models. Injury mechanism also affected follow-up adherence. Compared with patients with TBI caused by motor vehicle crashes, patients with TBI caused by biking or other sports had lower odds of full adherence over partial adherence (AOR = 0.4; 95% CI: ). DISCUSSION In our sample of children hospitalized for a TBI and instructed to follow up at this urban academic hospital (n = 352), only 53% had full adherence with followup appointments; 27% were partially adherent. We set a high bar for full adherence: patients had to have attended all recommended visits within 4 weeks of the recommended follow-up window and be subsequently discharged with no further recommended care. Previous research in adults with severe TBI has shown that those who received early comprehensive rehabilitation in a continuous chain of acute and rehabilitation care had better outcomes 12 months postinjury than adults in a delayed rehabilitation group. 24 Thus, though additional research is needed to track the long-term outcomes of individuals injured during childhood or adolescence, there is some evidence to suggest that earlier-initiated and continuous follow-up may help improve outcomes following TBI. In the population examined in this study, insurance status, age, cause of injury, and follow-up department were associated with follow-up adherence. Medical insurance status has been previously shown to be a significant enabling factor that affects healthcare utilization by patients with a variety of health conditions In our study, insurance status was associated with full

5 Follow-up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury 5 TABLE 1 Characteristics of pediatric patients with TBI by follow-up instruction groups, No follow-up instructions Follow-up outside hospital network Follow-up inside hospital network Total N Row % N Row % N Row % N Row % Total N Col % N Col % N Col % N Col % P Sex.30 Female Male Age, y < Race.08 White Black Hispanic Other/unknown Insurance.40 Medicaid/Medicare Private Uninsured Cause of injury.00 Motor vehicle crashes/motorcycle Fall Bike/other sports Pedestrian Others Injury Severity Score (ISS).12 ISS ISS ISS ISS (continues)

6 6 JOURNAL OF HEAD TRAUMA REHABILITATION TABLE 1 Characteristics of pediatric patients with TBI by follow-up instruction groups, (Continued) No follow-up instructions Follow-up outside hospital network Follow-up inside hospital network Total N Col % N Col % N Col % N Col % P Glasgow Coma Scale (GCS) a.39 GCS 13+ (mild) GCS 9-12 (moderate) GCS 3-8 (severe) Head AIS a (mild/moderate) (severe) (critical) Type of TBI.03 Non-specific TBI Type 3 TBI (least severe) Type 2 TBI Type 1 TBI (most severe) Length of stay, d Disposition <.0001 Home Rehabilitation Transfer Others Abbreviations: AIS, Abbreviated Injury Scale; ICD-9-CM, The International Classification of Diseases, Ninth Revision, Clinical Modification; TBI, traumatic brain injury. a Indicates variables with missing values (n < 10).

7 Follow-up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury 7 TABLE 2 Characteristics of pediatric patients with TBI who were instructed to follow up within the hospital network by adherence status, Adherence Status None Partial Full Total N Row % N Row % N Row % N Col % P Total Follow-up instruction 0.64 Nonspecific Specific a Follow-up department <.0001 More than 1 department Physical medicine and rehabilitation only Primary care physician only Sports medicine concussion clinic Neurosurgery only Sex 0.82 Female Male Age, y Race 0.59 White Black Hispanic Other/unknown Insurance 0.00 Medicaid/Medicare Private Uninsured Cause of injury 0.20 Motor vehicle crashes/motorcycle Fall Bike/other sports Pedestrian Others Injury Severity Score (ISS) 0.70 ISS ISS ISS ISS Glasgow Coma Scale (GCS) b 0.47 GCS 13+ (mild) GCS 9-12 (moderate) GCS 3-8 (severe) Head AIS b 0.61 Head AIS 1-2 (mild/moderate) Head AIS 3-4 (severe) Head AIS 5-6 (critical) Type of TBI 0.84 Nonspecific TBI Type 3 TBI (least severe) c Type 2 TBI d Type 1 TBI (most severe) e (continues)

8 8 JOURNAL OF HEAD TRAUMA REHABILITATION TABLE 2 Characteristics of pediatric patients with TBI who were instructed to follow up within the hospital network by adherence status, (Continued) Adherence Status None Partial Full Total N Row % N Row % N Row % N Col % P Length of stay, d Disposition 0.57 Home Rehab Abbreviations: AIS, Abbreviated Injury Scale; ICD-9-CM, The International Classification of Diseases, Ninth Revision, Clinical Modification; TBI, traumatic brain injury. a Specific is defined as date, time, and location of appointments given at discharge. b Indicates variables with missing values (n < 10). c Type 3 TBI: No intracranial injury and no loss of consciousness (LOC). d Type 2 TBI: Injuries with no recorded evidence of intracranial injury, and LOC of less than one hour, or LOC of unknown duration, or unspecified LOC. e Type 1 TBI: Intracranial injury or moderate or prolonged LOC, shaken infant syndrome (SIS), or injuries to the optic nerve pathways. adherence, but it did not have a significant impact when comparing nonadherent patients with those who were partially adherent. Other needed resources such as access to transportation, caregiver time off work, and household income could not be examined in this study but should be considered in future research. Older children were also slightly more likely to be partially adherent but less likely to be fully adherent. The differences across age groups are not readily explained with our current analysis. Patients with sports injuries were less often fully adherent when compared with those involved in motor vehicle crashes, but there were no differences in partial adherence between these 2 groups. Medical clearance for return to play might be a motivating factor in partial adherence in this patient population, as a 2013 law in our state mandates written permission from a licensed healthcare professional to return to play. 28 We found that hospitalized children with TBI were referred to many different departments even within the same pediatric institution. Our study tracked follow-up care in 4 departments, only (PM&R, primary care, neurosurgery, and sports medicine). Patients with follow-up at more than 1 department were more likely to be partially adherent rather than nonadherent, but they were less likely to be fully adherent. This highlights the challenges faced by families who may be referred to multiple specialties for their child s long-term follow-up care. Physician or therapist time spent with patients may affect the likelihood of returning for care, and differences may exist across these departments. Currently, at our institution, patients may receive their follow-up care in a number of clinic settings. At the time of this study, scheduling models were not consistent across departments. For example, in some settings, caregivers were required to call to schedule. In other clinics, appointments were made prior to discharge with or without caregiver involvement. Future research should include caregivers and families to help clarify what scheduling model would be most beneficial to promote adherence. Potential systematic changes to follow-up care should be evaluated, including best days of the week, times of the day, and the role of specialty contact during the hospitalization. Previous researchers have reported that a designated trauma clinic can significantly improve follow-up care adherence. 29 Because of the growing understanding that patients with TBI have acute and long-term rehabilitation care needs, hospitals should consider developing a continuous chain of treatment that integrates acute care, rehabilitation, and long-term follow-up. 24,30,31 It is also noteworthy that 8.6% of patients admitted to the hospital with TBI had no follow-up instructions listed in their chart. These families were possibly educated regarding long-term follow-up, but they did not receive written instructions on their discharge paperwork. In addition, 11.4% of patients were referred to physicians outside of the specialty pediatric network, and thus adherence could not be assessed. Research is needed to assess the comfort and knowledge of primary care physicians and pediatricians in relation to the longterm challenges associated with pediatric TBI.

9 Follow-up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury 9 TABLE 3 Factors associated with follow-up adherence among pediatric patients with TBI who were instructed to follow up within the hospital network, Partial/nonadherence Full/partial AOR 95% CI P AOR 95% CI P Follow-up instruction Nonspecific 1.0 Referent 1.0 Referent Specific a Follow-up department Physical medicine and rehabilitation only 1.0 Referent 1.0 Referent More than 1 department <.0001 Sports medicine or PCP Neurosurgery only Sex Female 1.0 Referent 1.0 Referent Male Age, y Referent 1.0 Referent Race White 1.0 Referent 1.0 Referent Black Hispanic Other/unknown Insurance Medicaid/Medicare 1.0 Referent 1.0 Referent Private Uninsured Cause of injury Motor vehicle crashes/motorcycle 1.0 Referent 1.0 Referent Fall Bike/other sports Pedestrian Others Glasgow Coma Scale (GCS) b GCS 13+ (mild) 1.0 Referent 1.0 Referent GCS 9-12 (moderate) GCS 3-8 (severe) Disposition Home 1.0 Referent 1.0 Referent Rehabilitation Abbreviations: AIS: Abbreviated Injury Scale; AOR: Adjusted Odds Ratio; ICD-9-CM: The International Classification of Diseases, Ninth Revision, Clinical Modification; PCP, primary care physician; TBI, traumatic brain injury. a Specific is defined as date, time, and location of appointments given at discharge. b Indicates variables with missing values (n < 10). Limitations Our findings should be interpreted with awareness of certain limitations. One limitation is that charted documentation may not fully and accurately reflect verbal instruction and education given to patients, as discussed earlier. Educating parents/guardians about the importance of follow-up care may significantly improve adherence with follow-up appointments. Second, this study had a relatively small sample size with small numbers of patients in some categories. Third, we were only able to analyze follow-up visits made within the hospital network where the EMR is shared and medical charts could be reviewed. Some families may have chosen to follow up with a pediatrician or other primary care physician. Fourth, in this pilot project, we did not track the number of recommended appointments for each patient that likely affects adherence. We are doing this in our ongoing rehabilitation research project. Fifth, because our study is limited to one academic pediatric

10 10 JOURNAL OF HEAD TRAUMA REHABILITATION hospital, our results may not be generalizable to other hospitals across the United States. Finally, because of the limited scope of this project, we were not able to assess the association of adherence with better long-term outcomes. CONCLUSION On the basis of this retrospective chart review of children admitted with a TBI to a large, urban children s hospital with a level 1 trauma center, we found that nearly half of children and adolescents with TBI missed follow-up appointments. This has significant implications for children and adolescents who have sustained a TBI and who may have unmet medical, educational, or psychosocial needs. Certain factors appeared to put children with TBI at risk of failing to comply with followup care appointments after inpatient discharge, namely insurance status and requests to follow up in multiple departments. 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