Impact of the absence of a designated healthcare proxy preadmission in adults 65 years or older with operative traumatic brain injury.

Abstract

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in older adults, often necessitating complex medical decisions during the acute care phase. Authors of this study examine the impact of the absence of an established healthcare proxy (HCP) on clinical outcomes, hospital course, and healthcare costs in older adults who underwent operative management of TBI. At a large, urban, level 1 trauma center, a retrospective cohort study was conducted in patients 65 years of age or older who underwent operative management for TBI in the period from 2015 to 2021. Patients were stratified by the presence or absence of an HCP preadmission. Univariate and multivariate logistic analyses were performed. Outcomes of interest included mortality, functional recovery, overall hospital length of stay (LOS), and ICU stay. The financial implications of prolonged ICU stays were estimated using published cost data. Among the 74 patients eligible for study inclusion, 28.4% (n = 21) did not have a designated HCP preadmission. These patients were more likely to undergo craniectomy (38.1% vs 9.4%, p < 0.01), and they experienced longer median ICU stays (12.5 vs 6 days, p = 0.02) and overall hospital stays (15 vs 9 days, p < 0.01). Only 11.3% of patients with an HCP underwent tracheostomy placement compared to 42.9% of those without an HCP (p < 0.01). Furthermore, those without HCPs were more likely to undergo gastrostomy (42.9% vs 18.9%, p = 0.03) and had significantly higher in-hospital mortality (52.4% vs 22.6%, p = 0.01). At the last follow-up, they had worse functional outcomes, with fewer attaining a modified Rankin Scale score ≤ 3 (20.0% vs 65.9%, p < 0.01). Craniectomy (OR 6.99, 95% CI 1.14-42.69, p = 0.04) remained significant after multivariate analysis, controlling for overall LOS, cardiovascular disease, procedure type, tracheostomy placement, gastrostomy placement, and primary care physician in the medical record. The absence of a designated HCP in older adults with operative TBI is associated with significantly higher mortality, worse functional outcomes, and longer hospitalizations. These findings highlight the need for proactive advance care planning and routine HCP designation discussions for older adults. Routine HCP designation could reduce unnecessary invasive care, improve patient-centered outcomes, and lower healthcare expenditures in this vulnerable population.